SEPTEMBER 2012 • COVERING THE I-4 CORRIDOR Nemours Children’s Hospital Opens Doors to Advanced Pediatric Care Local Care Designed �FOR Families, BY Families’ Experts at providing big hope for the tiniest hearts. The last words a new parent wants to hear are “life-threatening heart condition.” No one understands this emotional rollercoaster more than Florida Hospital for Children. Our full cardiac program is led by a team of experts including our medical director Constantine Mavroudis, MD, one of the nation’s leaders in cardiac care. He collaborates with some of the country’s top cardiologists and surgeons right here in Orlando, so there’s no need to travel for advanced surgical procedures. Our kid-friendly environment with Doc Fu and the Health Team comforts both patients and parents. The possibility for a long, healthy and productive journey for your child begins right here at Florida Hospital for Children. FloridaHospitalForChildren.com/Heart | (407) 303-KIDS (5437) contents 4 SEPTEMBER 2012 CENTRAL FLORIDA EDITION  COVER STORY Coming to Orlando in October: Nemours Children’s Hospital and Health Campus Photo: mage courtesy of Skanska USA Nemours Children’s Hospital will be home to some of the top pediatric specialists in the country and will offer specialized care that is not currently available in Central Florida. The 60-acre pediatric health campus has been designed FOR families BY families and will offer family-centered specialty care, education and state-of-the-art hospital services. The pediatric team at Nemours will provide expert care to children of Central Florida and beyond. They are actively working to bring the latest advances in research and treatment to all children. Nemours Children’s Hospital 19 Photo: PROVIDED BY HEART OF FLORIDA REGIONAL MEDICAL CENTER SPECIAL FEATURE  Heart of Florida Regional Medical Center is celebrating 15 years of providing quality care at its current location on Highway 27 in Davenport. After a six-month development phase, Heart of Florida recently unveiled its $9.5 million expansion into the fifth floor. Open since June 24th, all 31,000 square feet of the new floor is dedicated to the Center for Women’s Health, offering 10 large birthing suites, 20 post-partum beds, an expanded nursery and two dedicated operating rooms. With space freed up elsewhere in the hospital, the Pediatrics Department is growing, too, expanding care for women and children at Heart of Florida. DEPARTMENTS 3 FOR YOUR ENTERTAINMENT 30 First Pediatric Bone Marrow Transplant Unit Opens in Central Florida 31 Powerball & Real Estate Offer Similar Choices! 2 FROM THE PUBLISHER 10 MARKETING YOUR PRACTICE 12 PULMONARY AND SLEEP DISORDERS 14 PHARMACY UPDATE 16 Behavioral Health 33 CURRENT TOPICS 18 Medical Malpractice Expert Advice 36 ADVERTISERS INDEX 23 ORTHOPAEDIC UPDATE 25 DIGESTIVE AND LIVER UPDATE 28 CANCER FLORIDA MD - SEPTEMBER 2012 1 FROM THE THE PUBLISHER PUBLISHER FROM II am pleased to bring you another issue of Florida MD. Cancer in all its forms touches millions of lives. Iam pleased to bring you another issue of Florida MD Magazine. It’s hard to imagThe disease is particularly devastating when the victim is a child. The family dynamic is strained. ine anyone notdofamiliar withtothe of Dimes and the there workisthey do to To Hope, a nonParents wonderwho whatis to and where go March for support. Fortunately Runway profit organization that provides direct support and assistance to the children and families in the Central Florida community.themselves I’ve asked them to tell a little about their organization. you have a patient or always reinventing to create newusprograms and services. Coming upIf next know a family that could benefit from their services please pass along the information below. Please join month is the annual March for Babies. It’s a wonderful team-building opportunity for me in supporting the Runway To Hope and the fine work they do. Best regards, tions on how you and your family can join the march or how to form a team for your whole practice. I hope to see some of you there. Donald B. Rauhofer Warm regards, Publisher Runway To Hope is a non-profit organization founded in September 2010 by Mark and Josie NeJame. Runway To Hope’s mission is to serve and provide direct support to the children and families in the Central Florida community who have been impacted by Donald B. Rauhofer pediatric cancer. Assistance includes but is not limited to research, education, technology and family assistance. Publisher/Seminar Coordinator The organization aids these children and their families by partnering with Arnold Palmer Hospital for Children, Florida Hospital for Children, corporations, local businesses and philanthropists to raise funds and awareness so that progress made locally will benefit children with cancer, worldwide. When Join moreallthan a million people nationally walking inand March of Dimes, March for Babies and Saturday, April 24this a special fashion raising money to help give baby start! To Invite your family and friends It’s signature charity eventevery of the yearaishealthy the Runway Hope Spring Fashion Soiree. The highlight of the evening 7am Registration 8am show featuring more than 60 incredible and brave children, ages 2 to 18, all who are currently battling or have Walk overcome their to join you in March for Babies, or even form a Family Team. You can also join with cancer. Modeling much more than clothing, these courageous children show off the truest beauty of all – their unwavering spirits. your practice and become a team captain. Together you’ll raise more money and share Where The Runway To Hope Spring Fashion Soiree is a celebration of these children and their incomparable strength and courage. a meaningful experience. Lake Lily Park, Maitland Runway To Hope relies heavily on the pediatric oncologists at both Arnold Palmer Hospital for Children and the Florida Hospital for Children, as they are our strongest connection to thetochildren in need. TheyFor reach out information to Runway Toon Hope helping Some keys success:and Askfamilies your friends, more March Steps for New Users: us identify children and families who are infamily need and of assistance or who can benefit from events like the Runway To Hope Spring colleagues to support you by for Babies please call: 1.Fashion Go toSoiree, marchforbabies.org Beauty Bash, Boys Bash and the other events of which we are so lucky to have them be a part. Phone: (407) 599-5077 2. Click JOIN A TEAM Fax:us (407) 599-5870 To learn more about Runway To Hope please visit www.runwaytohope.org email at info@runwaytohope.org. 3.Phone Search for your team name in the reason why people do not donate is that Central Florida Division  407-802-1544, 189 S. Orange Avenue, Orlando, Florida 32801. no one asked them to give (don’t be shy)! search box. 341 N. Maitland Avenue, Suite 115 Emailing them is an easy way to ask. Maitland, FL 32751 4. Click on your team name 5.Coming UP Next Month: The cover You’re story done! focuses breastpage surgeon Dr. Youron personal has been Olga Ivanov at the Comprehensive Breast Health Center at Florida created for you and you are readyHospital to begin Celebration Health. Cancer and Dermatology. password for futureEditorial reference.focuses on fundraising! ADVERTISE IN IN FLORIDA FLORIDA MD MD ADVERTISE PREMIUM REPRINTS REPRINTS PREMIUM For more information on advertising in in Florida MD, call Publisher Donald the Florida MD Central Florida Edition, Rauhofer at call Publisher Don Rauhofer at (407) 417-7400, (407) 417-7400, fax (407) 977-7773 or fax (407) 977-7773 or Reprints of cover articles or feature stories in Florida MD are ideal for stories in Florida MD are ideal for promoting your company, practice, promoting your company, practice, serservices and medical products. vices and medical products. 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Publisher: Donald Rauhofer Associate Publisher: Joanne Magley Photographer: Donald Rauhofer / FloridaMD Photographer: Tim Kelly / Tim Kelly Portraits, Contributing Writers: NancyMD DeVault, Harinath Donald Rauhofer / Florida Magazine Sheela, MD, Jorge Guerrero, Jill Weinstein, Contributing Writers: JoanneMD, Magley, Sam RPh, D. Huysman, Matt Gracey, Pratt James RPh, Mitchell Levin, Psy.D, MD, Jennifer Jennifer Thompson, Gehrold, Thompson, VincenzoCorey Giuliano, MD,Farah DavidR. S. Kablaoui, Candidate Klein, MD,PharmD Stephen P. Toth, CLU, Jennifer Roberts Ana Espinosa Designer: Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Florida MD Magazine published by SeaforNotes Seminars, Oviedo, FL 32762. Callis (407) 417-7400 moreMedical information. PA, P.O. Boxrates 621856, 32762. CallPlease (407) 417-7400 for on Advertising uponOviedo, request.FLPostmaster: send notices more information. rates upon FL request. Form 3579 to P.O. Advertising Box 621586, Oviedo, 32762.Postmaster: Please send notices on Form 3579 to P.O. Box 621856, Oviedo, FL 32762. Although every precaution is taken to ensure accuracy of published materials, Florida MD cannot be held responsible for opinions Although every precaution is taken to ensure accuracy of published expressed or factsMD expressed by cannot its authors. Copyright 2012,forSea Notes materials, Florida Magazine be held responsible Media. All rights reserved. Reproduction in whole or in part without opinions expressed or facts expressed by its authors. Copyright 2010, written permission is prohibited. Annualreserved. subscription rate $45.in Sea Notes Medical Seminars. All rights Reproduction whole or in part without written permission is prohibited. FOR YOUR ENTERTAINMENT The Orlando Philharmonic Opens the Pops Series with “Wicked Divas” The Orlando Philharmonic Orchestra celebrates its 20th anniversary this season. Music Director Christopher Wilkins sums up the programming for this special period in the orchestra’s history. “This milestone year brings a sense of occasion to every concert. It is a season of great repertoire, star appearances, and community connection. We are especially pleased to offer works like Prokofiev’s Romeo and Juliet and Elgar’s Enigma Variations that display so brilliantly the virtuosity of our musicians.” Nowhere is this sense of occasion more apparent than in the Pops Series. “The Pops Series,” explains Wilkins, “is filled with joy and spectacle, offering Central Florida’s diverse community a range of musical styles and experiences to choose from. Broadway (Wicked Divas), Family Entertainment (Home for the Holidays) and the Great American Songbook (Michael Andrew’s My Funny Valentine) inspire programs that are attractive, diverse, and attention grabbing. The year is capped by a full production of Frank Loesser’s Pulitzer Prize-winning musical, How to Succeed in Business Without Really Trying.” The 5-concert Pops Series opens on Saturday, October 13 with wicked good fun! The first program is titled Wicked Divas. It’s a concert of diva showstoppers from Broadway, opera and popular music and is highlighted by selections from the Tony Award-winning musical Wicked. This program features the Elphaba (Nicole Parker) and Glinda (Alli Mauzey) from the Broadway production of Wicked and will showcase the breadth of their high-flying talents. In addition, favorites from the “untold tale of the witches of Oz,” the program also includes favorites from Gypsy, Ragtime, Titanic and opera selections from George Bizet’s Carmen. Andrew Lane returns to the Philharmonic stage to conduct this concert. In 2010, Maestro Lane concluded seventeen years as Resident Conductor and Principal Pops Conductor of the Orlando Philharmonic Orchestra. Under his leadership, the orchestra expanded its concert offerings to include pops, community concerts, family concerts, and educational concerts, which reached over 60,000 people each season. A dynamic and popular pops conductor, Maestro Lane serves as Pops Conductor of the Sarasota Orchestra and will lead that ensemble for all their subscription pops concerts for the 2012-2013 season. His pops concerts have included Banford Marsalis, Deborah Gibson, Peter Schickele, Arturo Sandoval, Roy Scheider, Doc Severinsen, Broadway star Davis Gaines, and many other renowned artists. He has been featured as conductor in 25 CD recordings produced by Madacy Entertainment Group of Quebec, Canada. Mr. Lane has also been a featured guest conductor with the Florida Orchestra, The Naples Philharmonic, Rochester Philharmonic, Asheville Symphony and San Antonio Symphony. In October of 2010, he was chosen by Bank of America as a “Local Hero” for his commitment to music education in Central Florida. United Arts of Central Florida named Andrew Lane “Music Educator of the Year” in 2012. All concerts in the Pops Series are offered on Saturdays at 2:00 p.m. and 8:00 p.m., at the Bob Carr Performing Arts Centre, located in downtown Orlando. Tickets are priced at $17, $29, $39, $55 and $70. The Pops Series schedule includes: OCT 13 – Wicked Divas NOV 24 – Home for the Holidays FEB 9 – My Funny Valentine MARCH 30 – Cirque de la Symphonie MAY 11 – How to Succeed in Business Without Really Trying To purchase tickets or to learn more about this series or the Classics, Focus and Opera Series, call the Box Office at (407) 770-0071 or visit www.OrlandoPhil.org.  FLORIDA MD - SEPTEMBER 2012 3 COVER STORY Nemours Children’s Hospital Opens Doors to Advanced Pediatric Care Local Care Designed �FOR Families, BY Families’ By Nancy DeVault, Staff Writer Just over three years after breaking ground on Nemours Children’s Hospital, the facility will open its doors to its first patient on Oct. 22, 2012 in what is known as Lake Nona Medical City. The historic achievement will grant Central Florida families and statewide residents alike access to long awaited, much demanded pediatric specialty care. With just 50 freestanding pediatric hospitals in the nation, Nemours Children’s Hospital will be the region’s only entity solely offering exceptional pediatric medicine including emergency treatment, prevention programs, and most importantly, a wide range of medical services, including specialties that are not currently available in Central Florida, which will provide intensive and acute inpatient care, in addition to outpatient services covering more than 40 disciplines. Since the conception of the Nemours Foundation in 1936, this large pediatric health system has operated with a “for families, by families” mission. Today, the Nemours health system directly impacts care for 250,000 children annually through personalized treatment plans offered throughout 28 clinic and hospital facilities located in Delaware, Florida, New Jersey, and Pennsylvania. Nemours will have great influence in advancing pediatric medicine and research, in addition to economic stimulus, in Orlando. In fact, thus far, Nemours Children’s Hospital has hired more than 750 associates comprised of more than 200 trained nurses, 50 skilled physicians and surgeons, an experienced visionary ad- ministration team, and hundreds of other accomplished clinical and organizational staff positions. “This hospital will represent how the Nemours Foundation believes care ought to be given to children in the 21st century,” stated David Bailey, MD, MBA, president and chief executive officer of The Nemours Foundation. “It’s all about providing care and support to children and the entire family unit, while effectively allowing health care professionals to implement superior, quality care.” That goal has remained a driving force during the formation process, and will finally take effect on a grand scale next month. Parents also will continue to have access to Nemours Children’s Clinics located throughout the state including Destin, Jacksonville, Lake Mary, Orange Park, downtown Orlando, Pensacola, and Viera. Decision Making is a Family Affair Barbara Meeks, RN, MSN, MBA, chief nurse executive for Nemours Children’s Hospital, explains that pediatric medicine is a personal family affair, and therefore, Nemours Children’s Hospital embodies a patient-family centered model of care. “When you are taking care of a sick child, you’re truly taking care of the whole family. It’s definitely not exclusive to one or the other – it’s both.” Meeks, who offers 35 years of pediatric health care experience, explains that though Nemours physicians may spearhead Photo: Image courtesy of Skanska USA Nemours Children’s Hospital will open to patients on October 22, 2012 in Lake Nona’s Medical City, near the Orlando International Airport. Patients will have a chance to control the color of the overhead lighting in the rooms, making NCH a colorful place at night and giving patients a sense of control over their environment. 4 FLORIDA MD - SEPTEMBER 2012 Paul and the other members have participated in monthly Family Advisory Council discussion and planning sessions, plus focused subcommittees. Results are integrated throughout the hospital, including details like the surface over patient beds. When one parent realized the reflective surface could scare a child to see himself with tubes in the arms and nose, the Family Advisory Council had the surface be made non-reflective. “As �frequent-users’ of healthcare and medical facilities, we know what our kids need and want more than hospital �traditional builders’. For example, while most might expect food services to only provide �healthy’ meal plans, my son actually requires a higher caloric intake including high fat, high sodium foods because his body’s ability to absorb and process nutrients is different,” Paul explains. She adds that the diverNemours Children’s Hospital is a hospital designed FOR families BY families. The sity among the Family Advisory Council members Nemours Family Advisory Council is made up of a group of local moms and dads who (referring specifically to the variety of medical conhave been there every step of the way, meeting regularly with the hospital architect and other executives to provide feedback on the design and policies of the hospital. ditions) is what will make the unique qualities of The Nemours Family Advisory Council is made up of members of the community, Nemours Children’s Hospital best set to serve the many of whom have children with health issues. needs of all families. “A fellow member utilizes a large motorized wheelchair for her daughter and treatment plans, parents know their child best and thus, their was able to communicate her concern of space, such as handicap knowledge and insight must count. “Parents, and of course our parking lot accessibility and size to room functionality.” Paul says children, are the end-users of what we do. Their direction for our that parents also were �testers’ for furniture such as desks, beds, new facility and service lines has been essential in establishing the best quality of care that fits their treatments needs.” On October 6, 2012 Nemours will host a Community Open House. To deliver this collaborative approach, Nemours Children’s Hospital established a Family Advisory Council to learn precisely what families desired for Orlando’s new pediatric medical facility. The council is made up of members of the community, many of whom have children with health issues. Under the executive ambassadorship of Meeks, roughly 25 local families, who have accessed the Nemours health system, were called to offer their consultative �expertise’ aimed to achieve a unique vision: “for families, by families.” Many of the passionate members are parents of children who have varying diagnoses and alignments, reflective of potential patient populations. Their personal feedback has guided aspects of facility and services development including planning, designing and building phases. “Sometimes children and their families spend days, weeks, or even longer in the hospital setting. Their comfort level – both physically and emotionally – is a key content to our healing environment. We gauged their hopes, wants and treatment frustrations,” adds Meeks. A public open house event for community families, patient families and Associate families. A great opportunity to tour the brand new hospital. The Family Advisory Council offered the direct perspective of parents like Lori Paul, an Orlando full-time mother to 8-year-old Max who received a diagnosis of cystic fibrosis at 13 months of age. Paul credits a Nemours physician with identifying her son’s rare symptoms that had previously been overlooked. “The caring team at Nemours has always felt like a family to us, truly invested in Max’s well-being. To be offered the chance to participate in the Family Advisory Council is simply the ultimate display of Nemours’ desire to foster genuine patient-family care. It’s unheard of in medicine and amazing!” Photo: Image courtesy of Nemours Photo: Image courtesy of Preston Mack COVER STORY FLORIDA MD - SEPTEMBER 2012 5 COVER STORY Photo: Image courtesy of Nemours perinatal guidelines for a low nurse to patient ratio (1:4 pediatrics and 1:3 intensive care unit), will also take a collaborative approach to leadership. “We’ve established a physician-nurse partnership to oversee the emergency department. It’s a joint responsibility for all aspects including financials, quality of care, patient satisfaction, staffing and so on. This strategy will ultimately eliminate silos among roles and create uniformity,” describes Meeks. Nemours fully understands the important role nature plays in the healing process and has incorporated natural settings into the facility’s design - both inside and out. The 10-thousand square foot garden on the fourth floor was designed with the help of occupational and physical therapists who will use the space as part of a patient’s rehabilitation. On the second floor, a seven thousand square foot balcony garden will offer a distraction to families while a child is in surgery. The balcony is just off the surgical commons area where families gather. It will also provide a quiet refuge for staff. Nemours Children’s Hospital’s one acre Discovery Garden will bring together nature and art by featuring five interactive areas devoted to the five senses. couches, electronic capabilities, and other items that parents will utilize in private patient rooms and/or waiting lounges. This patient-family centered influence stems back to Nemours Children’s Hospital’s objective to simply offer parents more choices. “It’s more than just physical design input. We’re expanding upon parent choices from comfortable, 24-hour access to be with your child to the ability to be present when the anesthesiologist puts your child to sleep before a procedure. We are listening to our parents and they see that in turn, the Nemours team is doing whatever we can to save the life of their child,” said Meeks. Lori Paul says she is especially looking forward to the �one-stop shop’ quality care experience that Nemours Children’s Hospital will provide to her son Max. The 60-acre, fully integrated health campus is split into two complimentary halves. One side of the facility is clinic-based, housing specialty pediatric practices; while the other is an advanced 95-bed hospital inclusive of a pediatric emergency department. “We won’t have to shuffle around town (or even to another city) to different doctor’s offices because all of Max’s specialty physicians - pulmonologist, nutritionist, gastroenterologist, social worker and other providers - will be here at one centralized location,” says Paul. By the end of the year, more than 750 people will be working at Nemours Children’s Hospital in Orlando. The medical staff has been training in the brand new, state-of-the art building in preparation for the specialized care they will provide Central Florida’s children on opening day, October 22, 2012. The nursing team of the system’s other children’s hospital, the Nemours/Alfred I. duPont Hospital for Children in Delaware was equally as vital in contributing design direction for functionality of private patient rooms. With an understanding that the nursing staff likely navigates patient rooms most frequently, their experience offered knowledge surrounding flow of care and space requirements affecting the ease of equipment’s mobility. Ultimately, such insightful planning on the front end for Nemours Children’s Hospital will allow staff to work more efficiently, resulting in cost savings. Nemours nurses, who follow 6 FLORIDA MD - SEPTEMBER 2012 Photo: Image courtesy of Nemours More than a dozen members of the Family Advisory Council are trained to interview finalists for positions at Nemours, including involvement in the hiring of top executive level positions. “The opinions of our Family Advisory Council truly were deciding factors in determining our leadership roles. For example, these members took part in the interview and hiring process of Randall W. Hartley who was ultimately hired as Chief Administrative Officer (CAO) for Nemours Children’s Hospital,” says Meeks. Unique features generated with the support of the Family Advisory Council are prevalent throughout all hospital floors. Embracing the power of nature, natural light fills the hospital. Outpatient surgery and surgical clinics are housed on the second floor, under the third floor neonatal and pediatric intensive care units. The fourth floor houses infusion departments and pediatric specialists, with the rehabilitation and neuro units comprising the fifth floor. Specializing in Pediatric Specialties Photo: Image courtesy of Nemours The Nemours health system utilizes HIMSS Analytics™ Database, an electronic records system which grades progress in effectively completing eight stages (0-7) of electronic technology. In 2011, Nemours Members of the Family Advisory Council have strong opinions about what a hospital should and should not include. They looked at the designs and made plenty of achieved Stage 7, this top level has only been accomchanges. Not only have they helped shape the hospital design but they are helping plished by 5 percent of hospitals nationwide. With a select the staff who will work there by interviewing candidates who want to become a comprehensive environment embodying numerous physician or a leader at Nemours. specialties, this high standard of metric tracking ensures patient safety and quality of care. “Medical personnel can ida, University of Florida (Pharmacy), the Orlando VA Medical easily access up-to-date medical records at the bedside of a paCenter and even Holmes Regional Medical Center. Dr. Finkel, is tient,” explains Terri Finkel, MD, PHD, chair of pediatrics and also an example of one of the rare specialists recruited by Nemchief scientific officer for Nemours Children’s Hospital. ours. She is one of just 250 pediatric rheumatologists practicing in the nation and earned a top distinction by U.S. News & World Dr. Finkel is charged with establishing cutting-edge pediatric Report. Prior to her arrival in Orlando, no one with this specialty research programs. She says Lake Nona Medical City offers rewas based in Orlando. “The U.S. Department of Health and Husearch synergy through collaborations and partnerships from the man Services estimates that the specialty field of pediatric rheuSanford-Burnham Research Institute, University of Central Flormatology actually requires at least 700 more trained physicians throughout the country. Our community is delivering Doctors at Nemours Children’s Hospital are not only treating children but that demand for care. This unique specialty will impact they are also looking for ways to cure them. Nemours’ location in Lake Nona many families who previously had no choice but to Medical City and its proximity to Sanford-Burnham has been enormously travel at least 50 miles outside of the area for rheumatic helpful in recruiting world-class physician-researchers. Nemours has partnered diseases such as childhood arthritis or autoimmune diswith Sanford-Burnham to house the lab space physicians need to search for new treatments and cures for childhood illnesses. eases,” says Dr. Finkel. Dr. Finkel says that while �Dr. House’ may be the fictional lead character on the FOX network’s hit television program, sometimes children’s health symptoms often do require �detective’ medicine. In addition to pediatric rheumatology, Dr. Finkel says Nemours Children’s Hospital will offer other specialties new to the Central Florida area and advancements to other specialties already present. Some new disciplines include, among other areas, chronic pain, pediatric rehabilitation, gastroenterology, behavioral health, fetal surgery, interventional radiology and muscular dystrophy – a specialty area for her husband and fellow researcher, Richard Finkel, MD. “Like many aligned with Nemours Children’s Hospital, we’re looking for cures, not just methods of treatments.” Dr. Finkel’s research is still needed to answer very basic questions stumping medical scientists: Why is this specific condition developing? How does the condition occur (in children)? What is the genetic makeup? She FLORIDA MD - SEPTEMBER 2012 7 Photo: Image courtesy of Preston Mack COVER STORY is now working to find solutions in her laboratory, located at the Sanford-Burnham Institute, regarding pediatric immune system diseases. Dr. Finkel says it’s important for parents to know that physicians at Nemours Children’s Hospital are leading the charge with pediatric research. “Patients will gain a sense of security and hope knowing their physician is a researcher. Research physicians are accustomed to asking questions and digging down for a precise, accurate conclusion. Therefore, we’re not going to accept the obvious and possibly flawed medical diagnosis and treatment approach when caring for pediatric patients. We can do better…we can save lives. That’s why our motto remains Your Child. Our Promise.”  NEMOURS CHILDREN’S HOSPITAL: Photo: Image courtesy of Nemours COVER STORY Fred Hames, right, Executive Vice President and General Manager of Skanska Florida, turned over the �key’ to Nemours Children’s Hospital to CEO, Roger Oxendale. The first wave of new associates were then welcomed into the building for the very first time. Adolescent Cardiology Critical Care Medicine Endocrinology Hematology/Oncology Hospitalist Services Infectious Disease Gastroenterology General Pediatrics Genetics Neonatology Nephrology Neurology Physical Medicine & Rehabilitation Pulmonology Rheumatology Behavioral Health Surgical Specialties Craniofacial Dental ENT General Surgery & Thoracic Interventional Radiology Neurosurgery Orthopedics Urology Ancillary Services Radiology Anesthesia Pathology 8 FLORIDA MD - SEPTEMBER 2012 Photo: Image courtesy of Nemours Medical Subspecialties Nemours Children’s Hospital’s has a modern aesthetic design that is fresh, progressive, and playful for children of all ages. Designed with the child of the information age in mind, technology was incorporated in creative ways. Nemours Children’s Hospital 13535 Nemours Parkway Orlando, FL 32827 Phone: (407) 567-4000 Nemours.org Get Connected to Nemours Children’s Hospital Facebook.com/Nemours Facebook.com/NemoursChildrens Twitter.com/Nemours YouTube Channels: • NemoursUpdates • YourchildOurpromise Flickr.com/Nemours Interventional Radiology Services now available at Dr. P. Phillips Hospital Every Tuesday, Dr. P. Phillips Hospital Interventional Radiology is now offering Interventional Outpatient Imaging procedures. Procedures include: t t t t t t Liver Lung Bone Kidney ć ZSPJE#JPQTZ 1FSDVUBOFPVT"CTDFTT Drainage t (BTUSPTUPNZ5VCF1MBDFNFOU t /FQISPTUPNZ5VCF1MBDFNFOU &YDIBOHF4UFOUJOH t 1MFVSY$BUIFUFS1MBDFNFOU 3FNPWBM t *7$'JMUFS1FSNBOFOU 5FNQPSBSZ t 1FSDVUBOFPVT5SBOTIFQBUJD $IPMBOHJPHSBN t 4QJOBM#JPQTZ t #POF#JPQTZ"TQJSBUJPO t $ZTU"TQJSBUJPO t -ZNQI/PEF#JPQTZ To schedule a patient appointment, please contact Karen Bolton, Interventional Radiology Coordinator: Phone: 321.842.7611 Fax: 407.351.1949 Email: Karen.Bolton@orlandohealth.com Sunrise via SMS Messaging at: Karen B’s DPHIR. FLORIDA MD - SEPTEMBER 2012 9 Marketing Your Practice Found Dead on Arrival: Public Relations By Jennifer Thompson, President of Insight Marketing Group Some people out there will argue that traditional public relations as it was once known is dead (or, rather, dying a slow death). Others will say that traditional public relations has simply evolved – that the message is the same but the delivery of the message is what has changed significantly. Either way, if you’re over 40 and aren’t an early adopter you may very well be looking at a career change if you’re in the public relations field. If you haven’t evolved the way your office delivers its public relations announcements, your efforts could be dead the second they arrive in the news editor’s inbox. Today, there are two types of public relations and then there’s a whole bunch of stuff in between. Proactive Public Relations – has an inbound marketing strategy at its core, and contains a strong content creation program and social media strategy which including news releases, timely story pitches and media alerts for media-friendly events. Reactive Public Relations – includes managing your reputation and responding to what’s being said about you, your medical practice (or any type of business for that matter) and your specialty across the internet and in the real world. Why Your Business Needs to be Proactive: If your practice is strictly reactive, you’re missing out on all sorts of free media attention and opportunity. The trick is knowing the proper ways to deliver the message so it’s most effective in garnering attention for your practice. Here are some stat’s that help illustrate why proactive public relations are so important: • 84% of all marketers agree that building consumer trust will become marketing’s primary objective in the near future. • More than 92% of buyers regularly check reviews online before making a purchase or service decision. • 78% of consumers trust peer recommendation while only 14% trust advertisements. • 4 out of 5 people say they have received advice via social media regarding what product or service to purchase. A recent study by Hubspot says that businesses that practice inbound marketing (where customers find you and CONTENT IS KING) increase leads an average of 4.2 times within a few months. It was also reported that 70% of customers (patients) prefer getting to know a company (your medical practice) via articles rather than advertisements. If you want potential customers to find you, then you need to 10 FLORIDA MD - SEPTEMBER 2012 put stuff out there for them to find (such as videos, articles, announcements, photos, presentations, etc.) and you need to do it consistently. You also need to post these efforts and push them through your own channels, rather than just relying on the traditional means of sending news releases and pitch letters. Do those still work? Sometimes. But having all of your bases covered and making sure your inbound internet presence is strong is part of the evolutionary process. When well executed, an effective content management plan will increase your organic search listings, protect your online reputation and drive traffic to your website. I would argue that if you are thinking about hiring a public relations firm to increase your visibility in the marketplace, consider hiring an inbound marketing firm that specializes in content development, social media and online reputation management in lieu of or in addition to a traditional PR team. They should have a clear understanding of the do’s and don’ts in public relations but also a clear understanding and ability to get your messaging out there in the non-traditional outlets. Long gone are the days where the only way to get noticed was to get picked up in your local newspaper or television station. Today, the internet (including social media and blogging) has afforded us the opportunity to bypass the traditional media outlets altogether and deliver our messages directly to patients. Public relations today has become more about search engine optimization (SEO) and getting your news indexed on the first page of Google than about getting your story covered on the evening news. If you are looking to get picked up in the traditional sense, one thing that certainly hasn’t changed in the realm of public relations is the need to make your business relevant to the news cycle. Making yourself relevant will increase your odds of getting picked up tenfold. Being relevant to the current news cycle is a great way to get your business and brand some good publicity and a nice way to help improve your online reputation at the same time (this means you are practicing both proactive and reactive public relations). For example, the Florida State Legislature recently passed a new youth concussion law requiring that all high-school athletes receive clearance from a physician following a suspected concussion-related injury on the field in practice or during a game. We saw this as an opportunity to get one of our clients positioned with the local television news as an expert on youth athletic injuries and overuse injuries. We also saw this as the right time to an- Marketing Your Practice nounce our client’s new baseline testing concussion program for area high schools. Not only were they able to create some great content for their website, which will go a long way for their online reputation management, but they have received a good deal of traction with the news program as well. It’s this combination of traditional, nontraditional, inbound, outbound, proactive and reactive public relations that comes together to create the desired results and put more patients in your medical office’s lobby. And at the end of the day, after all the buzz words and trends, jockeying for position on Google, edits and rewrites, submissions and rejections, that’s what it’s all about. When evolution is put into practice and PR lives to fight another day, we know we accomplished our goal. Marketing Your Medical Practice: A Quick Reference Guide Are you ready to finally start marketing your practice? Visit www.InsightMG.com to learn how you can order your copy of “Marketing Your Medical Practice: A Quick Reference Guide” by Jennifer Thompson and Corey Gehrold on Amazon. Encapsulating their real world medical marketing knowledge and expertise, this easy-to-read book gives you all the tips and tricks you’ll need to start marketing your practice today in a fast, fun and friendly format – just like the articles in this series. To learn more, visit www.InsightMG.com. Looking for more information? Contact Jennifer Thompson today for a free consultation and marketing overview at 321.228.9686 or e-mail her at Jennifer@InsightMG.com. Jennifer Thompson is president of Insight Marketing Group, a full-service healthcare marketing group focused on digital and social media administration, referral and partnership development, creative services and graphic design, online reputation management/development and promotional products. She is co-author of Marketing Your Medical Practice: A Quick Reference Guide and an avid Twitter user, regularly posting medical practice marketing tips, articles and more at www.Twitter. com/DrMarketingTips. You can learn more about her and her company at www.InsightMG.com.  Central Florida Pulmonary Group, P.A. Serving Central Florida Since 1982 Specializing in: x x x x x x x x Asthma/COPD Sleep Disorders Pulmonary Hypertension Pulmonary Fibrosis Shortness of Breath Cough Lung Cancer Lung Nodules Our physicians are Board Certified in Internal Medicine, Pulmonary Disease, Critical Care Medicine, and Sleep Medicine Daniel Haim, M.D., F.C.C.P. Syed Mobin, M.D., F.C.C.P. Tabarak Qureshi, M.D., F.C.C.P. Daniel T. Layish, M.D., F.A.C.P., F.C.C.P. Eugene Go, M.D., F.C.C.P. Kevin De Boer, D.O., F.C.C.P. Francisco J. Calimano, M.D., F.C.C.P. Mahmood Ali, M.D., F.C.C.P. Andres Pelaez, M.D. Francisco J. Remy, M.D., F.C.C.P. Steven Vu, M.D., F.C.C.P. Pranav Patel, M.D., F.C.C.P. Ahmed Masood, M.D., F.C.C.P. Ruel B. Garcia, M.D., F.C.C.P. Downtown Orlando: 326 North Mills Avenue East Orlando: 10916 Dylan Loren Circle Altamonte Springs: 610 Jasmine Road 407.841.1100 phone | www.cfpulmonary.com | Most Insurance Plans Accepted FLORIDA MD - SEPTEMBER 2012 11 PULMONARY AND SLEEP DISORDERS State of the Art: Medical Thoracoscopy By Jorge Guerrero, MD WHAT IS MEDICAL THORACOSCOPY? Medical Thoracoscopy is a minimally invasive procedure that involves the use of a high definition endoscopic camera that is introduced percutaneously (via the patient’s chest) in order to access the pleural space. This allows for a remarkable exposure to the pleura and the lung itself, therefore allowing the operator to perform both diagnostic and therapeutic interventions with pinpoint precision. Unlike Video-Assisted Thoracoscopic Surgery (VATS) used by thoracic surgeons, Medical Thoracoscopy is performed by an interventional pulmonologist trained in this procedure. While VATS requires endotracheal intubation, general anesthesia and a hospital stay after the procedure, medical thoracoscopy is done under conscious sedation and patients may be discharged home the same day of the procedure to resume their normal daily activities with no restrictions. INDICATIONS The procedure is indicated for the diagnosis and treatment of patients with recurrent pleural effusions of unknown etiology, suspected tuberculous pleural effusions, chylothorax and for those that have malignant pleural effusions (regardless of cell type), including malignant mesothelioma. Furthermore, in lung cancer, it is used not only as a diagnostic procedure, but also for staging purposes in order to guide oncologic therapy. Medical Thoracoscopy is also indicated for those patients with benign, recurrent pleural effusions (such as may occur with connective tissue disease, post-cardiac surgery and diuretic or dialysis resistant pleural effusions due to congestive heart failure or renal failure). The procedure not only allows for sizable tissue biopsies of the pleura and intrathoracic tumors, but it also permits definitive treatment of the pleural effusion with a single procedure. Another application involves the treatment of a persistent pneumothorax in patients who are not candidates for general anesthesia and VATS pleurodesis. In these patients, medical talc can be instilled via the medical thoracoscope into the pleural space in order to treat the persistent pneumothorax. DIAGNOSTIC YIELD AND THERAPEUTIC OUTCOMES The yield of Medical Thoracoscopy in the diagnosis of malignant pleural effusion is 95%, regardless of cancer cell type. This surpasses the diagnostic yield of repeated thoracentesis, where the yield plateaus at around 60%. Dr. Guerrero obtains pleural The yield of thoracentesis is biopsies using Medical even lower in patient with pleuThoracoscopy (actual patient). ral effusions due to lymphoma or mesothelioma. Tuberculosis currently is the cause of only 10% of all pleural effusion in the United States. However, the ramifications of missing a diagnosis of pleural tuberculosis (or the side effects of the anti-tuberculosis medica12 FLORIDA MD - SEPTEMBER 2012 tions if forced to treat based on incomplete data) are significant. Medical Thoracoscopy has a yield of 95-98% for the diagnosis of tuberculous pleural effusions, significantly higher than the expected yield for thoracentesis (10-35%) Or closed pleural biopsy (36-86%). Therapeutic outcomes are viewed in terms of resolution of the pleural effusion. Available data from prospective evaluation of patients have been published with a follow up of up to 6 months, showing complete control of the pleural effusion in 83% of the patients. However, non-published observational data suggests that it actually results in permanent control of the pleural effusion. State of the art protocols combining mechanical pleurodesis with talc pleurodesis can achieved Dr. Guerrero insufflates complete control in at least 90% medical talc guided by Medical of the cases. Thoracoscopy in order to treat a recurrent malignant pleural Complications are rare with effusion (actual patient). this procedure with a mortality risk of 0.09% and major complication rate of only 1.9% (which include prolonged air leaks, empyema, acute lung injury and bleeding). Contraindications to this procedure include uncorrectable coagulopathy, severe thrombocytopenia and severe hypoxemia. When comparing Medical Thoracoscopy with other modalities used to diagnose and treat patients with pleural disease, the advantages of the former are substantial. Overall, this is a safe and efficacious procedure that is minimally invasive, avoids hospital admission and provides long lasting results to the patient. Dr. Jorge Guerrero, MD, graduated from Universidad Javeriana School of Medicine in 2002. He then completed a fellowship at Harvard Medical School in Boston, Massachusetts in Adult Tracheobronchomalacia Novel Clinical Research. Next, Dr. Guerrero completed an Internal Medicine Residency at Tufts University School of Medicine in Boston, Massachusetts and a Pulmonary and Critical Care fellowship at Georgetown University School of Medicine. Dr. Guerrero went on to complete another fellowship at Harvard Medical School – Beth Israel Deaconess Medical Center in Boston, Massachusetts in the Division of Interventional Pulmonology. Since finishing his third fellowship, Dr. Guerrero became a member of Central Florida Pulmonary Group in Orlando as of August 2012. Dr. Guerrero may be contacted at 407.841.1100 or by visiting www.cfpulmonary.com.  OVERWEIGHT? OVERDIABETES? OVERHYPERTENSION? If you are over dealing with the pain, isolation, and health issues that accompany obesity, there is help. The Bariatric Program at Florida Hospital Celebration Health — a Bariatric Center of Excellence and holds the Gold Seal of Approval in health care — has already helped hundreds of patients get over the issues that accompany obesity and back to a healthier, more active life. Visit www.YouCanGetOverIt.com to hear from our patients and register to attend a FREE Information Session. Information Sessions are offered every Wednesday at 6 pm at Celebration Health. Is bariatric surgery right for you? Scan this QR code with your smart phone to join the conversation! Metabolic Medicine & Surgery Institute 400 Celebration Place | Celebration, FL 34747 | (407) 303-4425 www.YouCanGetOverIt.com CH-12-8299 www.Facebook.com/MMSIcelebration FLORIDA MD - SEPTEMBER 2012 13 PHARMACY UPDATE Compounding for Autism By Jill Weinstein, RPh and Farah R. Kablaoui, PharmD Candidate “I love compounding pharmacists because only they can prepare what I want to prescribe: pure formulations without dyes, filler, and additives at whichever dose and concentration the patient needs and in whichever form the patient will best accept.” — Dr. James A. Neubrander, owner and director of the Autism Clinical Research Center of New Jersey, who specializes in the use of subcutaneously injected methyl-B12 to treat autism. Do you treat any patients with autism? Chances are that you do as the Centers for Disease Control and Prevention reports that 1 in 88 children suffer from this disorder. Autism was defined as a lifelong neurobiological disorder but some physicians have found that it may be treatable. Autistic patients exhibit a variety of symptoms including behavioral problems, poor attention and concentration, and depression. It is important to, if not cure the patient, alleviate some of the symptoms. Serotonin reuptake inhibitors can be used to treat depression, anxiety and obsessive-compulsive disorder. Amitriptyline, diazepam, lorazepam, and bupropion have also been used for anxiety and behavioral problems. Antipsychotics such as risperidone or olanzapine can help stabilize patients that experience hyperactivity or aggression. Compounding pharmacists can dispense commonly used medications for autism in different drug delivery vehicles and at various strengths for specific patient needs. Antifungals, antibiotics, transdermal chelation agents and nutritional supplements can also be formulated. There can be many contributing factors leading to a lack of compliance to medications in autistic patients. These patients may experience symptoms of being overly sensitive to sight, sound, touch, smell, or taste. Medications can taste too bitter or feel gritty, topical creams may feel abnormal on their skin or a capsule may be tough to swallow resulting in noncompliance. Sulfation, methylation and immune system function appears to be impaired in autistic patients resulting in dysfunctional metabolism, biochemical function and systemic detoxification. Glutathione and methionine are peptides responsible for protecting cells from damage. Low levels of these peptides have been observed to correlate with elevated levels of heavy metals and the body’s oxidative stress. Sulfation abnormalities result in difficulties in concentration, attention and cognition. Methylation abnormalities result in hyperactivity and poor concentration. These abnormalities are also linked to allergies and intestinal tract inflammation. Recent clinical studies have revealed a high occurrence of gastrointestinal symptoms, inflammation, and dysfunction in children with autism. Evidence has recommended that vitamins, minerals and supplements should be given to support the oxidative stress the body is exhibiting. Methylation is important for a variety of fundamental physiological effects including proper sequencing and production of brain chemicals, such as dopamine and serotonin, which is utilized in motor coordination, mood and focusing. Methylation enhances the production of glutathione which is needed to protect cells against heavy metals and chemicals. Methylcobolamin, a methylated form of vitamin B-12, is a supplement used for the deficiencies caused by abnormal methylation. The best method for administering methylated B-12 is subcutaneously. Compounding pharmacies can compound methylated B-12 for patients in a preservative-free formulation to reduce pain to the area. Pharmacy Specialists Compounding Pharmacy can customize prescriptions to be delivered in an innovative dosing form to better serve patients. Individually developed dosage forms may include suspensions, suppositories, gummies, lollipops, troches, sublingual tablets, subcutaneous injections and topical applica- Yale-Trained Gastroenterologists C E S Compassionate, Caring �^ŽƉŚŝƐƟĐĂƚĞĚDĞĚŝĐĂůĂƌĞ F Left to Right: Srinivas Seela, MD, Harinath Sheela, MD, Seela Ramesh, MD Our Expertise Includes: tBarrett’s Esophagus tBravo Placement tCapsule Endoscopy tColonoscopy tEndoscopic Ultrasound tEsophageal Motility Disorders tManometric and pH Studies tUpper Endoscopy: Advanced Diagnosis and Therapeutic Endoscopy ESCF accepts most insurances. ․Bilingual Staff․ The Endo-Sugical Center of Florida is now open at 100 N. Dean Rd., Ste 102 Orlando, FL 32825. The Center provides the highest quality outpatient endoscopic services. 407.384.7388 WWW.DLCFL.COM 14 FLORIDA MD - SEPTEMBER 2012 escf_6.11.indd 1 8/3/2012 3:32:27 PM PHARMACY UPDATE tions. Common ingredients omitted in formulations due to food or drug allergies include sugar, dye, wheat, casein, gluten, and yeast. As taste can be a concern, especially in children, the compounding pharmacy staff will work with parents and the patient to determine what flavor will be best for patient adherence. The possibilities are endless! Why not cater to the needs of autistic patients with a formula and delivery form that is created especially for them? Call Pharmacy Specialists today at (407) 260-7002 or visit us online at www.makerx.com to get the answers for your questions today! References available upon request. Validated Quality Coming UP Next Month: The cover story focuses on breast surgeon Dr. Olga Ivanov at the Comprehensive Breast Health Center at Florida Hospital Celebration Health. Editorial focuses on Cancer and Dermatology. International Academy of Compounding Pharmacists Reputation Management 101 Central Florida’sFREE ONLY PCAB-Accredited™ Seminar and Lunch Compounding Pharmacy! Farah R. Kablaoui, PharmD Candidate South Carolina College of Pharmacy, USC Campus is currently on rotation at Pharmacy Specialists. Jill Weinstein, RPh, graduated You're invited to an informative, interactive from University of Florida and is the presentation that details everything you clinical pharmacist who does horneed to know about physician rating sites mone, nutrition and weight loss conlike HealthGrades.com sultations at Pharmacy Specialists. Pharmacy Specialists is proud to be the only pharmacy in all of Central Over 80% of Buyers Change Their Decision Florida and one of only 129 pharmacies in the country that are accredited #BTFE0òPG/FHBUJWF3FWJFXT. by the Pharmacy Compounding AcMore Than 92% of Buyers Reguarly Check Reviews creditation Board (PCAB). We meet Online #FGPSF.BLJOHB1VSDIBTFPS4FSWJDF%FDJTJPO or exceed ALL standards for sterile as • Now acceptingand your toughest well as non-sterile compounding patient or medication challenge Hosted By we are the only USP 797 and USP Personalized Medicine 795 validated• compliant pharmacy FREE • Community Clinical Pharmacy Lunch Provided in all of central Florida. Currently, SEPTEMBER 26 The MacGyvers of Compounding! Walk Away with Easy Do-It-Yourself Tips •A Shortage Sam Pratt, RPh at Drug Pharmacy Special- Resource12:00 p.m. – 1:00 p.m. Attendees receive a complimentary copy of Fairwinds Credit Union ists is the only Full Fellow of the InterMarketing Your Medical Practice: A Quick Reference Guide Community Room more information please call national For Academy of Compounding /"MBGBZB5SBJMt0SMBOEP'- Pharmacists in the Central Florida area. Call to or Pharmacy visit us Specialists at 393 Maitland Avenue, check with a clinical pharmacist for Altamonte Springs, FL 32701 suggestions and recommendations. www.makerx.com For additional information please Register at www.mor-of.net/events.htm call (407)260-7002, FAX (407) 260For more information call 407.382.5660 or email Events@InsightMG.com 7044, Phone (800) 224-7711, FAX Thanks to Our Support Sponsors  (800) 224-0665. 407-260-7002 or 800-224-7711 Space is Limited, RSVP Today! Free Educational Lunch FLORIDA MD - SEPTEMBER 2012 15 Behavioral Health What Does the Affordable Care Act mean for Family Caregivers? By James D. Huysman, Psy.D., LCSW What does the Affordable Care Act (ACA) mean for caregivers? That seems to be the question on a lot of minds since the Supreme Court upheld the legislation. As we trudge the road less taken to find our place in the new order of healthcare made possible by the ACA, there are surely more questions than answers at this point. So, let’s concentrate on what we know about it. The Affordable Care Act is a federal statute signed into law in March 2010 as a part of the healthcare reform agenda of the Obama administration. Minus the political dramas and traumas around it, it was designed to address the three-legged dilemma we see in healthcare today: cost, access and quality. It means that healthcare delivery is going where it has not gone before. That means that healthcare delivery is going where it has not gone before. I know what you are thinking. “Beam me up, Scotty. Let’s do this!” Right? Great, you’re on board, but are you prepared? One of the ACA’s best features is that it makes a patient-centered approach to health and wellness possible. This makes each individual a partner in their own health and wellness. In addition, it focuses on the concept of prevention and even allows what have been categorized as “alternative” modalities to be integrated into the mainstream of 21st century medicine, opening the door to embracing palliative care as a process that includes the caregiver, and so much more. It will not be easy; change never is. Progress may be chaotic and slow. So it’s even more important to take a collective deep cleansing breath and get in touch with ourselves – Yes, I said it. A mu book is titles…Take YOUR Oxygen First. As a caregiver, you are part of the transitional process. You must also understand that to be dedicated and empowered you just take care of your mental health. Anxiety, panic, depression and a host of other treatable behaviors are at their highest level of activity. If the ACA is about prevention and wellness for the patient, it is as important to practice wellness and prevention as a family caregiver. Start by taking care of your health and wellness medically and seek strong mental health to avoid burnout by identifying a therapist, joining a self help support group or simply developing a program for yourself that allows for you to stay balanced and on two sturdy legs. Now is the time to re-evaluate your caregiving goals. How can I be included in the process? What do I need that is not being provided? How can I be a better partner in my own wellness and that 16 FLORIDA MD - SEPTEMBER 2012 of the one I care for? Imagine the healing power for someone in the grips of a chronic illness to know that their medical team is in touch with its own wellness. The French dramatist Eugene Ionesco said, “Art requires that one place everything in doubt all over again”. What an appropriate metaphor for finding the positive in accepting and molding the impact of the ACA. The ACA is not perfect but it can be a process that, if we are up to the challenge, can direct us, as caregivers, to becoming real partners in the continuum of care. Perhaps the most important question of all is for each of us to ask ourselves, “What kind of healthcare delivery and support system do I want in this country for myself, my kids and my grandkids? As we ask these questions as a family caregiver, remember that “let peace (& wellness) begin with me. Our loved ones will learn an important from us and can take that lesson to navigate the future for themselves, as well. Now that’s something to think about! Dr. James D. (Jamie) Huysman, Psy.D., LCSW began his career serving in vice presidential roles at freestanding psychiatric and chemical dependency treatment centers. Subsequently he was called upon to integrate behavioral healthcare with medical services in the same capacity at several national medical surgical hospital groups. Today, he is part of the WellMed Medical Management team that advocates for and integrates behavioral health into primary clinic settings to create better qualitative outcomes and care efficiencies. He received his Masters in Social Work from Barry University and Psy.D. from California Southern University. He is also certified as an addictions professional and compassion fatigue therapist. A popular and engaging speaker, Dr. Huysman keeps an active schedule presenting on a variety of relevant topics for professional caregivers and service providers around the country. He can be reached at drj@drjamie.com or through his website www.drjamie.com.  WelcomING E S T E E M E D S U R G E O N S The Center for Specialized Surgery proudly welcomes board-certified surgeons J. Pablo Arnoletti, MD, FACS and Sebastian de la Fuente, MD. Both physicians are fellowship-trained surgical oncologists, specializing in pancreatic, hepatobiliary and digestive neoplasms. They engage in a multidisciplinary team approach, offering treatment in minimally-invasive laparoscopic and robotic surgery. J. Pablo Arnoletti, MD, FACS Sebastian de la Fuente, MD t Board Certified, General Surgery t Board Certified, General Surgery t Fellowship, Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA t Fellowship, Surgical Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL t Residency, General Surgery, MCPHahnemann University, Philadelphia, PA t Associate Professor of Surgery, University of Alabama, Birmingham, AL t Residency, General Surgery, Duke University Medical Center, Durham, NC t Fluent in English and Spanish t Fluent in English and Spanish 2415 Orange Avenue, Suite 400, Orlando, FL 32804 www.CenterForSpecializedSurgery.com The Center for Specialized Surgery FPMG-12-8989 Now Accepting New Patients. Call 407.303.7399 for Appointments. FLORIDA MD - SEPTEMBER 2012 17 Medical Malpractice Expert Advice Focusing On Patient Safety vs. Tort Reforms By Matt Gracey of Danna-Gracey – The Malpractice Insurance Experts Often in medicine’s tort-reform efforts, we get so focused on the politics of changing unfair laws that we lose sight of the low-hanging fruit. How many dollars have gone into trying to convince the politicians to limit the number of lawsuits against doctors and hospitals? How much progress have we really made, given that a bunch of states in the last year or two have overturned their caps on non-economic damages? How many years have some great medical leaders spent rallying their peers to contribute money and time to their political action committees focused on changing our oftentimes-ridiculous court systems as it relates to complex medical cases? Maybe it is time that we weigh these efforts against the results and against using those efforts toward other options for change, since obviously this “top down” approach is not working as well as we had hoped. The bottom-up approach is to focus on patient safety. Maybe we should focus on the findings of the 2006 Health Grades Study showing that 54.9% of patients received the recommended care. Maybe we should focus on the studies comparing a number of our medical-results measures to those in other parts of the world. We just might find that serious efforts like those under way on so many fronts, such as those of the National Patient Safety Foundation, will prove more fruitful for lowering malpractice-insurance lawsuits in the future. Certainly, doctors and hospitals working with doctors and hospitals toward change will probably be much more productive, more rewarding, saner, and maybe even more fun than doctors and hospitals continuing to work with politicians and expecting different results. Matt Gracey, Jr. is a medical malpractice insurance specialist with Danna-Gracey, an independent insurance agency based in downtown Delray Beach with a statewide team of specialists dedicated solely to insurance coverage placement for Florida’s doctors. To contact him call (800) 966-2120, or email: matt@dannagracey.com.  START WEIGHT SEPT. 2010: 207 LBS. • END WEIGHT DEC. 2010: 166 LBS. Pathology Lab Results — Patient: SP Age: 63 Sex: Male Before Diet Lipid Panel Result 08/28/2009 Ref Range Result Cholesterol H 278 (80-199)mg/dL Triglycerides H 199 (30-150)mg/dL HDL Cholesterol 51 (40-110)mg/dL LDL Cholesterol H 187 (30-130)mg/dL VLDL Cholesterol 40 (10-60)mg/dL Risk Ratio(CHOL/HDL) H 5.5 (0.0-5.0)Ratio 8/26/10: 9/24/10: Tissue Fat % 26.3% 21.1% Body Scan Results Tissue (g) 83,019 78,045 Fat (g) 21,864 16,449 After Diet 09/20/2010 180 82 55 109 16 3.3 Lean Muscle (g) 61,155 61,596 Please Note: Gain of 441g of muscle and a fat loss of 5,415g in 30 days! Individual results may vary. For information call 407-260-7002 or email Sam@makerx.com. 18 FLORIDA MD - SEPTEMBER 2012 SEPTEMBER 2012 • COVERING THE I-4 CORRIDOR • SPECIAL FEATURE Heart of Florida Regional Medical Center Women’s and Children’s Services Expansion Aids Expanding Families FLORIDA MD - SEPTEMBER 2012 3 SPECIAL FEATURE Heart of Florida Regional Medical Center Women’s and Children’s Services Expansion Aids Expanding Families By Nancy DeVault, Staff Writer Heart of Florida Regional Medical Center is celebrating its 15th anniversary of providing quality care for Polk County residents and area tourists alike at its current location on Highway 27. Operated by Health Management Associates, Inc. (HMA), which has seventy hospitals in non-urban locations across multiple states, Heart of Florida has evolved from a 51-bed facility to a 193-bed facility complete with comprehensive health care services. Priority service lines and specialty sites include bariatric surgery, cardiac services, Center For Day Surgery, clinical laboratory services, da Vinci® robotic surgery, diagnostic imaging, emergency department, Orthopedic and Joint Replacement Center, Designated Stroke Center, therapy and rehabilitation center, pediatrics and Center for Women’s Health.. “Heart of Florida Regional Medical Center has grown considerably to meet the demands of our community, covering Polk County and the four corners area. Advancements in technology aid our medical teams in offering a magnitude of care options for patients,” said Don Breeding, Chief Executive Officer. “Last year, we treated 81,000 patients including approximately 50,000 emergency room visits.” Breeding joined the executive leadership team at Heart of Florida in 2008 as the Chief Nursing Officer, offering more than thirty years of hospital-based nursing and administrative expertise. After being named CEO in 2011, Breeding’s leadership paired well with the talent of the hospital’s nearly 200 physicians and hundreds of other clinical and staff positions. Recent performance awards validate this superior partnership and the collaborative commitment to provide high quality, compassionate healthcare services. 20 FLORIDA MD - SEPTEMBER 2012 Center for Women’s Health Following a six-month development phase, Heart of Florida Regional Medical Center recently unveiled its $9.5 million expansion into the fifth floor which added 35 new hospital rooms and equipment upgrades. Open since June 24th, all 31,000 square feet of the new fifth floor is dedicated to the Center for Women’s Health. The space includes 10 large birthing suites, 20 post-partum beds, an expanded nursery (triple the previous space), two dedicated operating rooms, and a unique HUGS® security system. “We’ve created our niche for women’s health care to offer preventive services, diagnostic testing and treatment for health issues at all ages and all stages of life,” explains Breeding. The Center for Women’s Health provides obstetrics care with a unique feminine touch catering to all needs of mommy and baby. Plus, the facility offers a broad range of gynecology services including da Vinci® robotics-assisted surgery, hormone therapy and menopausal care, incontinence and urogynecology, family planning, infertility treatments, and breast health, including digital mammograms, MRI, ultrasound and stereotactic needle biopsies, and bone density screenings. “We are fortunate to have state-of-the-art equipment in our innovative Center for Women’s Health to benefit work flow and of course patient care,” explains Lisa Bishop, RNC, BSN, Director of Women’s and Children’s Services, adding that building architects accounted for extra space to accommodate usage and storage of Heart of Florida Regional Medical Center is positioned on Highway 27 in Haines City, four miles south of I-4. Photo: PROVIDED BY HEART OF FLORIDA REGIONAL MEDICAL CENTER (HOFRMC) “Of Polk County’s five hospitals, Heart of Florida Regional Medical Center was named as the top-ranking hospital in the Lakeland/Winter Haven metropolitan area in U.S. News & World Report’s 2011-2012 Best Hospitals rankings,” said Breeding. Then, earlier this year, Heart of Florida Regional Medical Center was highlighted as the sole Polk County hospital to receive an A grade delivered by The Leapfrog Group on its Hospital Safety Score report. “The Leapfrog distinction helped authenticate that we are hitting on all cylinders for our patients and their families, ensuring not only their safety but proper and effective treatment plans. Overall, we aspire to be servant leaders providing compassionate and quality care.” Breeding says among the many service lines, he sees great potential for growth in a number of programs, including: cardiology (which recently added a third cath lab), joint replacement, pediatric unit (lead by a skilled pediatric hospitalist), and the recently expanded Center for Women’s Health. the help of the OB/GYN practice co-founder Mark Alkass, M.D., an obstetrician with residency training from the University of Maryland in Baltimore. This team has grown to include five OB/GYN physicians, two midwives, and a nursing staff with three office locations in Davenport, Lake Wales and Winter Haven. At that time, Dr. Alkass says he and his associates delivered just 100 babies annually and now deliver well over 1,000 newborns annually. “It’s exciting to see our comprehensive obstetrics and gynecological services expand and encompass a fully dedicated floor for our female patients,” said Dr. Alkass, who personally treats over 5,000 gynecological cases each year. He says that gynecologic surgery using da Vinci® robotics has been a welcome advancement to better serve both patient and physician. “It’s not a �one tool fits all’ for patients, yet the majority of our patients do receive improved outcomes with Mark Alkass, M.D.,OB/GYN Natalia Wetterer, M.D., Pediatrics fewer risks or complications by opting for robotics assisted treatments,” says Dr. Alkass, a certified da Vinci® trained surgeon large medical robotic devices. “We have spacious, private patient who has completed over 100 da Vinci® robotic surgeries. “As a phyrooms, as well as private waiting areas. These details are apprecisician, the robotics assistance has great impact on level of fatigue ated by patients and families and accommodate the diverse patient during surgery.” populations visiting our hospital. There is a great difference between families waiting for a baby’s arrival to those awaiting surgery Some robotic assisted procedures performed by Dr. Alkass have completions from other gynecological procedures.” included hysterectomy, myomectomy, endometriosis resection, and sacrocolpopexy. According to Dr. Alkass, the da Vinci® tool delivers The Center for Women’s Health offers pregnancy services inprecision and control thanks to three robotic arms, a camera, and cluding Childbirth Education Classes and the CuddleBugs® mater3D magnifier. Depending on the procedure, the technique shortnity program, a free platform designed to provide answers for new ens hospital stays to usually allow next-day discharge for patients and expectant moms from the earliest stages of pregnancy through (and in some cases day of surgery release). post-delivery, and guidance on newborn care. Bishop says the hospital delivers approximately 90 to 100 babies per month. The Center for Women’s Health is committed to providing complete health care options for patients of all ages, and in all “We recently rolled out a new VIP Package to enhance the stages of life. memorable delivery experience. It’s simply a little something special to reward and pamper new mommies and daddies during their Pediatrics Growth hospital stay,” said Bishop. The optional $200 plan provides new With the Center for Women’s Health physically transitioned parents with a welcome basket, robe and slipper socks, scrubs for completely to the fifth floor of Heart of Florida Regional Medical the birthing coach, upgraded bath products and linens, celebration Center, space has freed up to expand other departments including dinner for two on day of delivery, candlelight dinner the day of the pediatric unit which provides care for children birth through discharge, memento blanket and infant onesie, luggage tag/diaper age 21. bag tag, refrigerator in each suite, free baby photo package, and concierge support to schedule OB/Pediatric appointments. “The “We’ve grown into a 14-room pediatric unit,” said Natalia M. satisfaction of the birthing experience is surely improving here at Spacious rooms and state-of-the-art equipment combine with our maternity ward.” In addition to the emotional support and instruction of the licensed lactation consultant, parents truly value the added security – both physically and emotionally – of the special Hugs® security system. “This safety component is a lightweight bracelet worn by the baby during the duration of their hospital stay. It monitors skin contact on the newborn; therefore it won’t be prematurely removed. Plus, it causes the hospital doors to close and lock if the child is carried too close to an exit,” describes Breeding. Partnering Care Heart of Florida Regional Medical Center partners with the skilled providers from Heart of Florida OB/GYN Associates on many basic woman care services available through the Center for Women’s Health. In fact, the Heart of Florida women’s program was reintroduced to the community almost fifteen years ago with excellent medical care to provide a memorable experience for new families at Heart of Florida. Photo: PROVIDED BY HOFRMC PhotoS: PROVIDED BY HOFRMC SPECIAL FEATURE FLORIDA MD - SEPTEMBER 2012 21 SPECIAL FEATURE Dr. Wetterer says she has been charged with establishing partnerships with referring physicians and conducts speaking engagements. However, her main role is to serve as the primary care taker of all pediatrics patients. “I am the first and often the main point of contact for families upon arrival and throughout their child’s treatment stay. That typically means identifying the appropriate hospital specialists if needed, and serving as the communications channel for both our medical teams and patient families.” The da Vinci® robotics-assisted procedures are allowing physicians to provide surgical options to women that involve shorter recovery times with minimal scarring and blood loss. Photo: PROVIDED BY HOFRMC Wetterer, M.D., who has served as the pediatric hospitalist at Heart of Florida for two years, following her residency at St. Vincent’s Medical Center of Richmond in Staten Island, New York. “We typically average six to eight pediatric patients per day, but often reach ten pediatric patients daily.” Dr. Wetterer said that word-of-mouth satisfaction has truly been the (most effective) unsolicited grassroots marketing tool to increase the quantity of pediatric visits, and thus, expansion was a necessity of this welcomed growth. “We treat a variety of pediatric ailments such as asthma, gastroenteritis, orthopedics, ENT, and so on.” All of the equipment in the nursery of the new Center for Women’s Health meets 2012 NRP guidelines. Dr. Wetterer says the hospital is bringing a fresh, kid-friendly look to the pediatrics unit. “This detail may seem secondary, but with pediatric patients typically staying one to three days to complete treatments, we need a welcoming environment for their comfort.” Photo: PROVIDED BY HOFRMC “Heart of Florida Regional Medical Center is just the right size, giving patients extra space for comfort with great personalized services,” said Lisa Bishop. “Polk County is a huge region but our geographic location provides convenient access for the community. It’s a hometown feel.”  The Center for Women’s Health includes two dedicated operating rooms for women’s surgical needs. Contact Information 40100 Highway 27 Davenport, FL 33837 Phone: (863) 422-4971 www.HeartOfFlorida.com Phone: (863) 419-BABY Email: WomensHealth@hma.com www.WomensHealthAtHOF.com Explore Online Services Visit www.HeartOfFlorida.com for unique and convenient features such as: • Upcoming events •Online nursery •Patient e-cards • Bill pay services •Link to Cuddlebugs® Photo: PROVIDED BY HOFRMC See www.WomensHealthAtHOF.com for additional options, including: •Pregnancy calculator •Health library •Provider biographies •Center for Women’s Health services 22 FLORIDA MD - SEPTEMBER 2012 ORTHOPAEDIC UPDATE Ulnar Collateral Ligament Reconstruction (Tommy John Surgery) in the Throwing Athlete By Corey Gehrold You may not know who Tommy John is, but if you’re involved in the world of sports medicine, odds are you’ve heard the name before. Ulnar collateral ligament (UCL) reconstruction is performed on athletes, most commonly baseball pitchers, when they tear this important stabilizing ligament in their throwing elbow and the nonsurgical treatment options have failed. Named Tommy John surgery outside of the medical field, this procedure was first performed in 1974 by Dr. Frank Jobe on Major League Baseball pitcher Tommy John. At the time of the original Tommy John surgery, Dr. Jobe put his chances of recovering from the ligament injury at one in 100. Today, literature says that number is closer to the 90 percent mark thanks to advances in technology and modern medicine. “When the ulnar collateral ligament sustains a tear, the throwing athlete often complains of pain on the inside, or medial, part of the elbow as well as a loss of velocity and control on their pitch,” says Randy S. Schwartzberg, M.D., a board certified sports medicine specialist at Orlando Orthopaedic Center. “If non-surgical treatment fails for the UCL tear, the surgical treatment involves replacing the ligament with a tendon graft.” To ensure that the UCL can return to functioning as the stabilizing structure of the elbow, a complete replacement is necessary. Although it can heal, it often heals in a lengthened position, resulting in a loose condition that can hinder the throwing athlete from ever returning to the type of play they were accustomed to prior to ligament injury. “Damage to the ulnar collateral ligament can occur suddenly or gradually after continued stress on the throwing athlete’s elbow,” says Dr. Schwartzberg. Before discussing Tommy John surgery in-depth, the following is background on ulnar collateral ligament tears. Risk Factors Risk factors for tearing the UCL involve excessive use or repeated stress being placed on the ligament. In day-to-day activities, it’s very rare to injure the ligament. Most injuries occur in baseball because of the intense overhead motion and force used when winding up and releasing hundreds of pitches. Ultimately, the ligament becomes compromised and tears. “Other risk factors may include contact sports where one may fall on an outstretched hand, ultimately dislocating their elbow,” says Bradd G. Burkhart, M.D., a board certified sports medicine specialist and colleague of Dr. Schwartzberg’s at Orlando Orthopaedic Center. “We also see UCL ligament tears in other overhead athletes, such as volleyball and tennis players as well. Throwing mechanics and form also contribute to risk factors of the injury.” Symptoms Symptoms of the ligament injury that may ultimately lead to Tommy John surgery and a complete ligament reconstruction include pain on the inner side of the elbow. Many athletes also note a “pop” or “tearing” sensation at the site of the injury, according to Dr. Schwartzberg. “Then swelling and bruising may be noticeable after roughly 24 hours post injury,” he says. “Athletes will also notice newfound elbow stiffness and they may feel a slight numbness or tingling in the small and ring fingers of the injured arm.” Non-Surgical Treatment Randy S. Schwartzberg, MD Board Certified in Orthopaedic Surgery Board Certified in Sports Medicine Bradd G. Burkhart, MD Board Certified in Orthopaedic Surgery Specializing in Sports Medicine, Knee & Shoulder Surger A mild tear to the ulnar collateral ligament may heal on its own. Non-surgical treatment for the ligament tear consists of medications, ice and rest to relieve pain and swelling. Functional rehabilitation supervised by a skilled sports medicine athletic trainer or physical therapist is the most important component of non-surgical management. Surgical Treatment (Tommy John Surgery) Tommy John surgery is recommended to those that have sustained an acute rupture or partial tear of the UCL ligament and have failed non-surgical treatment. The procedure is performed under general anesthesia by a trained orthopaedic surgeon. Ligament reconstruction begins with an incision on the inner part of the elbow where the damaged ligament is removed. From there, holes are drilled to accommodate the new tendon grafts, often taken from the palmaris longus tendon found in the forearm or the gracilis tendon in the leg, according to Dr. Schwartzberg. These holes are drilled in the ulna and humerus bones of the elbow precisely where the ulnar collateral ligament attaches. “Then we place the new tendon into the sockets created in the ulna and humerus. The graft is then secured with fixation devices FLORIDA MD - SEPTEMBER 2012 23 ORTHOPAEDIC UPDATE to allow an accelerated rehabilitation approach,” says Dr. Schwartzberg. “After one week in a splint, the throwing athlete is placed into a hinged elbow brace with no range of motion restrictions. Rehabilitation commences with progressive functional activities leading up to an interval throwing program at the four month postoperative mark.” Potential complications of the surgery include infection, elbow range of motion loss and ulnar nerve issues. However, the rate of these complications is very small following the procedure. Recovery “Typically we see a return to the sport of choice following surgery within 6-9 months,” says Dr. Burkhart. “Rehab can be carried out at home, but at Orlando Orthopaedic Center we recommend patients see our physical therapists to help guide their road to recovery.” Because the graft is very strong and fixation is so secure, early range of motion and rehabilitation is safe. Physical therapy is necessary to regain strength and range of motion in the elbow following Tommy John surgery and may begin following the first several weeks of recovery. “Although range of motion and strength about the elbow returns within a couple of months of the surgery, the throwing athlete still has a large amount of work to ready the elbow for throwing,” says Dr. Schwartzberg. “Emphasis on the entire kinetic chain during rehabilitation is critical. The throwing motion begins with the legs, involves the trunk and then the shoulder, elbow and wrist. Core strengthening is very important and a hard working and patient athlete can end up becoming a stronger, healthier throwing athlete.” Most patients make a complete recovery and return to normal activities with little to no change in their routine once fully healed. Want to Learn More About a UCL Reconstruction? Check out the “Latest News” section of www.OrlandoOrtho.com to watch Dr. Schwartzberg take you step-by-step through a UCL Reconstruction surgery.  Has Your Student-Athlete Patient Sustained a Concussion? We Can Evaluate and Clear Them to Return to Play. 7KHQHZ<RXWK&RQFXVVLRQ/DZUHTXLUHVWKDWDWKOHWLFWUDLQHUVDQG RUFRDFKHVUHPRYHDQDWKOHWHIURPDJDPHRUSUDFWLFHLPPHGLDWHO\ IROORZLQJDVXVSHFWHGKHDGLQMXU\3ULRUWRUHWXUQLQJWRSOD\WKHDWKOHWH PXVWEHHYDOXDWHGDQGUHFHLYHPHGLFDOFOHDUDQFHIURPDSK\VLFLDQ Our Concussion Network Services Include: ‡&RPSOHWHSK\VLFLDQHYDOXDWLRQ ‡&RPSXWHUL]HGQHXURORJLFDOHYDOXDWLRQ ‡&RPPXQLFDWLRQEHWZHHQSK\VLFLDQSDUHQWDWKOHWLFWUDLQHUDQGFRDFK &RQWDFW2XU2IÀFHWR6FKHGXOH<RXU3DWLHQW·V %DVHOLQH7HVWRU&RQFXVVLRQ(YDOXDWLRQ. 6DPH'D\1H[W'D\$SSRLQWPHQWV$YDLODEOH www.OrlandoOrtho.com/Concussion 407.254.2500. 5 Convenient "#*).#,(#.H.'/).'/,1!/Â.I/)#,!,2I!/Â!2#I!2#!,%I(#Â. Our Oviedo Office is Open on Saturdays! 9 a.m.-1 p.m. 24 FLORIDA MD - SEPTEMBER 2012 Digestive and Liver Update Update in GI and Hepatology By Harinath Sheela, MD CONSTIPATION Sodium phosphate enemas — Sodium phosphate enemas are used in the treatment of constipation and for preparation for flexible sigmoidoscopy. A retrospective series found that sodium phosphate enema use in older adults (mean age 80 years, range 61 to 89 years) was associated with complications including hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and EKG changes (prolonged QT interval). In patients over the age of 70 years, we suggest that warm water enemas rather than sodium phosphate enemas be used for the treatment of constipation. COLORECTAL CANCER SCREENING Flexible sigmoidoscopy for colorectal cancer screening — Results of the flexible sigmoidoscopy arm of the Prostate Lung Colorectal and Ovarian (PLCO) Screening Trial have been reported . A total of 154,900 men and women aged 55 to 74 were randomly assigned to screening with flexible sigmoidoscopy or to usual care, with median follow-up of 11.9 years. There was a 21 percent reduction in the relative risk of colorectal cancer (CRC) and a 26 percent reduction in the relative risk of death from colorectal cancer, comparing the screening arm with usual care. Although the incidence of both proximal and distal CRC significantly decreased, a reduction in mortality was seen only for distal cancer. There was significant contamination in the usual care group (among whom 47 percent underwent either sigmoidoscopy or colonoscopy), suggesting that the impact of sigmoidoscopy compared to no screening might be even greater than was seen in this trial. Mortality benefit for screening colonoscopy — Long-term follow-up of the National Polyp Study (NPS) population found that, at an average follow-up of 16 years, there was a 53 percent reduction in colorectal cancer (CRC) mortality in patients who had adenomas removed compared to the expected CRC mortality rate in the general population (based on data from the SEER program) . CRC mortality in the NPS for the first 10 years following polypectomy was the same for patients found to have adenomatous or nonadenomatous polyps. Although not a randomized trial, this is the first study to strongly indicate a CRC mortality benefit for colonoscopy. The magnitude of the results of this study may not be generalizable to community practice, because NPS colonoscopies were performed by a small number of trained endoscopists and reported rates of CRC following polypectomy were lower for the NPS than reported in other studies. Rates of postpolypectomy surveillance colonoscopies (81 percent in the NPS) may also be higher than is common in the community. Glucocorticoid therapy for eosinophilic esophagitis — Two small trials investigated the use of topical glucocorticoids for the treatment of eosinophilic esophagitis in adults, and both found improvement in histologic eosinophil counts. One trial randomly assigned 42 patients to swallow aerosolized fluticasone (880 mcg/day in two divided doses) or placebo for six weeks. Fluticasone was associated with a histologic response (>90 percent decrease in mean eosinophil count) but no significant improvement in dysphagia. In another trial, budesonide was administered to 25 patients either by nebulizer, with patients instructed to swallow the accumulated liquid, or by viscous slurry. Although patients who received the viscous slurry had a higher duration of mucosal contact with budesonide and lower eosinophil count, there was no significant difference in dysphagia symptom scores which improved in both groups. Dietary therapy for eosinophilic esophagitis in children — Dietary therapy is an effective treatment for eosinophilic esophagitis in children. An observational study compared outcomes in 98 children with eosinophilic esophagitis who had been treated with one of three diets: an elemental diet; a diet in which six foods associated with allergy were eliminated (ie, cow-milk protein, soy, wheat, egg, peanut, and seafood); or a skin prick allergy testing-directed elimination diet . Histologic remission occurred in children on all three diets (96, 81, and 65 percent, respectively). However, the odds of histologic remission were significantly higher in children on elemental diets compared with directed diets. Dietary therapy for eosinophilic esophagitis in adults — In an observational study of 50 adults with eosinophilic esophagitis, patients were treated with a six-food elimination diet for six weeks . A clinical response (decreased dysphagia) was seen in 94 percent, although the endoscopic appearance improved in 78 percent and only 74 percent had a reduction in the eosinophil count to less than 15 eosinophils/hpf on esophageal biopsy. A specific food was implicated in the 20 patients in whom follow-up data were available after gradual reintroduction of food groups. Skin prick allergy testing identified only 13 percent of the food triggers. This study suggests that food elimination diets may be an option for motivated adults. However, successful implementation of such diets requires a dedicated and informed nutritionist and willingness of the patient to make substantial lifestyle changes and to undergo multiple endoscopies to determine which food group is the trigger. ENDOSCOPY Sodium phosphate for flexible sigmoidoscopy — The preparation for flexible sigmoidoscopy typically involves two sodium phosphate enemas given the morning of the examination. HowFLORIDA MD - SEPTEMBER 2012 25 Digestive and Liver Update ever, sodium phosphate enemas have been associated with complications, particularly in older adults. A retrospective series found that sodium phosphate enema use in older adults (mean age 80 years, range 61 to 89 years) was associated with complications including hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and changes on the electrocardiogram (prolonged QT interval). As a result, in patients over the age of 70 years, the risks of oral preparations (eg, polyethylene glycol lavage or magnesium citrate) and sodium phosphate enemas need to be weighed for each individual patient before deciding upon an appropriate preparation. HEPATITIS B VIRUS INFECTION Vaccination of patients with diabetes mellitus — The Advisory Committee on Immunization Practices recommends that hepatitis B virus (HBV) vaccination be given to unvaccinated adults with diabetes mellitus who are ages 19 to 59 ]. For older patients with diabetes, vaccination can be administered at the discretion of the treating clinician based on the risk of acquiring HBV and the likelihood of an adequate immune response to vaccination. HEPATITIS C VIRUS INFECTION Treatment without peginterferon or ribavirin — Standard treatment regimens for hepatitis C virus (HCV) contain peginterferon and ribavirin, but a substantial number of patients cannot receive one or both drugs due to known intolerances or contraindications. Treatment regimens are being studied that do not use peginterferon or ribavirin. Two small studies (21 patients total) tested such regimens in patients with HCV genotype 1. Patients received 24 weeks of treatment with a combination of daclatasvir and asunaprevir, two experimental direct-acting antiviral agents. Viral loads 24 weeks after stopping treatment were undetectable in 14 of the patients (67 percent), including one patient who was only treated for two weeks. These preliminary studies suggest that HCV treatment without peginterferon and ribavirin may be possible. Drug interactions with boceprevir in patients with HIV — Boceprevir is a protease inhibitor used in the treatment of patients with HCV genotype 1 infection. If boceprevir is used in combination with certain ritonavir-boosted HIV protease inhibitors (eg, atazanavir, lopinavir, darunavir), the effectiveness of boceprevir as well 26 FLORIDA MD - SEPTEMBER 2012 as the ritonavir-boosted medications may be decreased. The US Food and Drug Administration recommends that patients taking boceprevir along with one of the listed ritonavir-boosted protease inhibitors should be closely monitored for potential HCV and HIV virologic rebound. HEPATOTOXICITY Flavocoxid — Flavocoxid is a prescription dietary supplement that is used to treat osteoarthritis. In a prospective study of 877 patients, four patients (0.4 percent) developed liver injury. In all four cases, liver tests returned to normal within 3 to 12 weeks of discontinuing the flavocoxid. Flavocoxid should be avoided in patients with known liver disease and should be considered Validated Quality International Academy of Compounding Pharmacists Central Florida’s ONLY PCAB-Accredited™ and AMA-Recognized Compounding Pharmacy! The MacGyvers of Compounding! PAIN GELS For more information please call 407-260-7002 or 800-224-7711 or visit us at 393 Maitland Avenue, Altamonte Springs, FL 32701 www.makerx.com Digestive and Liver Update as a possible etiology in patients with clinical manifestations of liver injury. HEREDITARY COLORECTAL CANCER Aspirin for chemoprevention in patients with Lynch syndrome — Individuals with Lynch syndrome have an 80 percent risk of developing colorectal cancer in their lifetime. While an earlier placebo-controlled trial (CAPP2) did not find a benefit for aspirin for adenoma or colon cancer prevention in patients with Lynch syndrome after a mean of 29 months of follow-up, a subsequent analysis found a marginally significant reduction in colorectal cancer incidence in the subset of patients treated with 600 mg aspirin per day for more than two years. A secondary analysis found a decreased rate of overall Lynch cancers in the aspirin-treated group. Further studies are needed to validate this potentially important result and determine if the benefits associated with aspirin outweigh the risks. NUTRITION Initiation of enteral nutrition in critically ill patients — Two strategies have been used to initiate enteral nutrition: incrementally increasing the infusion rate until the target maintenance rate is achieved or initiating the infusion at the target maintenance rate. The EDEN trial was a multicenter open-labelled trial that compared these approaches by randomly assigning 1000 mechanically ventilated patients with acute lung injury to receive either full enteral feeding or low-volume enteral feeding for six days, after which both groups received full enteral feeding. The trial found no differences in the number of ventilator-free days, 60-day mortality, or the frequency of infectious complications. However, the low-volume feeding group had less vomiting, smaller gastric residual volumes, lower mean plasma glucose levels, and less constipation. These data suggest that initial lowvolume enteral feeding has fewer undesirable effects than initial feeding at the target rate. esomeprazole, and pantoprazole, with methotrexate (primarily at high dose), may elevate serum levels and prolong the half-life of methotrexate and/or its metabolite hydroxymethotrexate, possibly leading to methotrexate toxicities. Harinath Sheela, MD moved to Orlando, Florida after finishing his fellowship in gastroenterology at Yale University School of Medicine, one of the finest programs in the country. During his training he spent significant amount of time in basic and clinical research and has published articles in gastroenterology literature. His interests include Inflammatory Bowel Diseases (IBD), Irritable Bowel Syndrome (IBS), Hepatitis B, Hepatitis C, Metabolic and other liver disorders. He is a member of the American Gastroenterological Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and the American Association for the Study of Liver Diseases (AASLD) and Crohn’s Colitis foundation (CCF). Dr. Sheela is a Clinical Assistant Professor at the University of Central Florida School of Medicine. He is also a teaching attending physician at Florida Hospital Internal Medcine Residency and Family Practice Residence (MD and DO) programs.  PROTON PUMP INHIBITORS C. difficile and proton pump inhibitors — Proton pump inhibitors (PPIs) may be associated with an increased risk of C. difficile-associated diarrhea (CDAD). The US Food and Drug Administration (FDA) issued a drug safety communication in February 2012 following a review of published literature. Most studies reviewed found that the risk of C. difficile infection or disease, including CDAD, ranged from 1.4 to 2.75 times higher among patients with PPI exposure compared to those without PPI exposure. The relationship between the risk of C. difficile infection and PPI dose and duration of use is uncertain. Given the potential risk of CDAD, the FDA has also recommended that providers prescribe the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Proton pump inhibitors in patients receiving high-dose methotrexate — The US Food and Drug Administration has issued a warning about use of proton pump inhibitors (PPIs) in patients receiving methotrexate, particularly high-dose methotrexate . Case reports and published population pharmacokinetic studies suggest that concomitant use of PPIs, such as omeprazole, FLORIDA MD - SEPTEMBER 2012 27 CANCER Marketing Your Practice Lung Cancer Screening: A New Standard of Care? By Jacques P. Fontaine MD, FACS Lung cancer is not the most common cancer in men, prostate cancer is. Lung cancer is not the most common cancer in women, breast cancer is. However, lung cancer kills more American men than prostate cancer. Lung cancer kills more American women than breast cancer, colon cancer and cervical cancer combined. Lung cancer is the leading cause of cancer related deaths in the United States. Although the incidence of smoking is slowly decreasing, the incidence of lung cancer continues to rise. The 5-year overall survival for lung cancer is 16% as compared to 97% with prostate cancer and 84% with breast cancer. There are two reasons for this. First, the tumor biology is very aggressive. Second, most lung cancers are diagnosed in advanced stages where prognosis is very poor. The great majority of early stage lung cancers are asymptomatic and discovered incidentally. The prognosis of very early stage, asymptomatic, lung cancers is comparable to that of prostate, breast and colon cancers. Certainly, smoking cessation and prevention programs aimed at adolescents and young adults is the best long term method to decrease the impact of this cancer on our society. However, the most practical and immediate method to improve the prognosis of our lung cancer patients is to diagnose them earlier when the chance of a cure is much better. Renewed interest has thus emerged in the significance of lung cancer screening programs. Successful, government funded, screening programs for prostate cancer, breast cancer, colon cancer and cervical cancer have been in place for years. Until recently, there were no screening programs for lung cancer, the number one cancer killer in America. Previous lung cancer screening programs using chest x-rays were ineffective. To determine whether CT scans were more sensitive and could be an effective screening tool, the National Cancer Institute (NCI) funded a large multicenter, prospective randomized trial which enrolled 53 456 patients between 2002 and 2004. The fact that so many patients were enrolled so quickly is a testament of patients’ willingness to enroll in lung cancer screening programs. Patients enrolled in this study were considered at high risk for developing lung cancer and consisted of asymptomatic men and women between the ages of 55 and 74 who had a 30 pack-year history of smoking. The patients were randomized to an annual CXR or to an annual CT Scan. A “positive” screen was a CT Scan demonstrating a 4mm noncalcified nodule. An astounding 24% of patients were found to have a “positive” CT Scan. Various investigational algorithms for these pulmonary nodules were used to determine which nodules 28 FLORIDA MD - SEPTEMBER 2012 were suspicious enough to warrant a biopsy. These “work-up” algorithms which included the use of PET Scans and repeat interval CT Scans were not standardized and therefore more realistic of generalized medical practice. Using proper “work-up” algorithms, only 8% of patients found to have pulmonary nodules were deemed suspicious enough to warrant a biopsy. This represented less than 2% of the screened population. Of the patients who did undergo a biopsy, 53% were found to have a lung cancer and the majority of the time (63%) it was an early Stage I cancer. Due to the fact so many of these lung cancers were detected at an early stage, this translated in a 20% reduction in mortality. The cost of having lung cancer screening covered by commercial healthcare insurance plans would be less than $1 per month for policy holders, far cheaper than breast cancer screening at about $3 a month. In terms of cost effectiveness, the cost per life-year saved would be below $19 000. This compares favorably to cost per life-year saved in breast ($31 000 - $52 000), colon ($19 000 - $29 000), and cervical cancers ($50 000 - $75 000). On the other hand, these results also highlight the fact that 47% of patients who underwent a biopsy did not end up having a lung cancer and therefore underwent an “unnecessary” biopsy. We can be reassured, however, that patients with pulmonary nodules deemed suspicious enough to require a biopsy were at very low risk of being harmed by a “negative” biopsy since the complication rate was extremely low at 0.05% due to the minimally invasive techniques used: bronchoscopy, percutaneous needle or thoracoscopy. Avoiding unnecessary scans or biopsies is of the highest priority to multi-disciplinary teams that specialize in lung cancer and use rigorous algorithms. With proper use of algorithms, 92% of patients found to have a pulmonary nodule on CT screening avoided a biopsy and none developed a lung cancer from a false negative screen. CT Scan screening for lung cancer not only impacts the survival from the disease but also the way we treat it. Surgical resection remains the best treatment modality with the highest cure rate for early stage lung cancer. Because lung cancers are typically diagnosed in advanced stages, however, even for those patients where lung resection is an option, often the cancers are too large to be amenable to minimally invasive, lung sparing, surgical techniques. Thus, another major advantage derived from CT Scan screening for lung cancer is the fact that the majority of these lung cancers are discovered at an early stage when they measure less than 2cm. These small tumors are ideally resected using minimally invasive techniques of thoracoscopy (VATS) or CANCER robotic surgery rather than using a more traditional, invasive thoracotomy. The costs of lung cancer screening is already covered by medical insurance carriers in Japan and some third-party insurance carriers in the United States are in the process of approving coverage for this screening modality. Nonetheless, lung cancer screening programs are already being offered throughout the country with an out-of-pocket patient cost of up to $350. The radiation dose from a screening CT is similar to that of a screening mammogram and 10 times lower than a regular diagnostic CT scan of the chest. Be sure and check out Coming UP Next Month: The cover story focuses on breast surgeon Dr. Olga Ivanov at the Comprehensive Breast Health Center at Florida Hospital Celebration Health. Editorial focuses on Cancer and Dermatology. our NEW and IMPROVED website at www.floridamd.com! �� The H. Lee Moffitt Cancer Center in Tampa, Florida offers lung cancer screening, which includes a consultation with our specialized multidisciplinary team. Appointments can be made by calling 1-888-MOFFITT. Our team treats more lung cancer patients than any other institution in Florida. Over 70% of our lung cancer resections are performed using minimally-invasive techniques including robotic, lung sparing surgery with results superior to the national average. Our surgical team has performed the most robotic lung surgery in the state of Florida as well. Jacques P. Fontaine, MD is a thoracic surgeon at H. Lee Moffitt Cancer Center in Florida who specializes in robotic lung surgery. He was chief resident in thoracic surgery at Brigham & Women’s Hospital – Harvard Medical School. Prior to joining the staff at Moffitt, he worked for the Department of Thoracic Surgery associated with Brown Medical School in Providence, RI. He has a special interest in lung and esophageal cancers as well as thymoma and mesothelioma. He is accepting new patients at Moffitt Cancer Center; appointments can be scheduled at (813) 745-2733.  "Jewett made my family feel like we were part of their family." Go to www.jewettortho.com and see the O’Lenick’s full story    No appointment necessary! Monday - Thursday: 7:30am - 8:00pm Friday: 7:30am - 4:00pm Saturday: 9:00am - 3:00pm Stirling Center 701 Platinum Point On Rinehart Road Lake Mary, FL 32746 407.206.4500   FLORIDA MD - SEPTEMBER 2012 29 First Pediatric Bone Marrow Transplant Unit Opens in Central Florida By Paul Gordon, MD On Thursday, August 16th, 2012, Florida Hospital for Children opened the first and only pediatric stem cell transplant unit in Central Florida. Stem cell transplantation (SCT) is a well established treatment for many otherwise fatal pediatric conditions. Allogeneic SCT involves the complete ablation of a child’s bone marrow with chemotherapy and/or radiation and replacement with donor stem cells from a volunteer bone marrow donor or umbilical cord blood (UCB) collected at the time of delivery. Autologous SCT involves the use of a patient’s own stem cells to replace the bone marrow after ablation with chemotherapy/radiation. Pediatric conditions cured with SCT include Leukemia, myelodysplastic syndromes (MDS), bone marrow failure syndromes such as Fanconi anemia, hemoglobinopathies such as sickle cell disease (SCD), metabolic conditions such as adrenoleukodystrophies and, immunodeficiencies. Many non malignant congenital conditions in pediatrics can be cured with SCT. We performed our first SCT June 23, 2011, and have performed 15 transplants so far. A passion of mine is sickle cell disease and we have successfully transplanted and cured three patients with sickle cell disease to date. Our new pediatric SCT unit is a beautiful 8 bed unit. The entire unit has a high efficiency (HEPA) air filtration system with positive pressure controlled rooms relative to the corridors and the outside to protect our patients. All the rooms are private, large and beautiful. We have age appropriate amenities patients and a family room for parents. Approximately 1100 pediatric allogeniec transplants are performed in the USA annually and about 100-120 of these occur here in Florida. About 50% of pediatric allogeneic transplants use UBC as the stem cell source and 50% bone marrow. There are three pediatric hematology/oncology practices in Central Florida and we were referring out 20-40 transplant patients per year to other facilities. Kids Beating Cancer (KBC) is an incorporated philanthropic group whose objective is to be the resource so that no child diagnosed with cancer, or related life threatening diseases will ever be denied treatment. KBC’s CEO and founder Margarette Geddes was one such Orlando parent whose son was diagnosed with a life threatening illness (MDS), needed a stem cell transplant and had to be transferred out of state. Her extremely difficult journey and subsequent loss of her son is a powerful testament that a SCT unit was needed in central Florida. The partnership of a grieving mother with a mission and a hospital with a vision and commitment to the children of Central Florida led us to where we are today and the opening of the new unit; “The Kids Beating Cancer Pediatric Transplant Unit” I received my stem cell transplantation training at St Jude Children’s Research hospital. I joined the team at FH to head the pediatric stem cell transplantation program about 18 months ago. I have a deep passion for families like Margaret. I have personally lost a close family member to cancer and really want to be the torch bearer of hope for families that have either failed standard therapies or require SCT for cure. I was immediately drawn to Margaret’s journey and story. I am committed that no child should have to leave home and travel far away for a SCT. 30 FLORIDA MD - SEPTEMBER 2012 Dr. Paul Gordon performing a bone marrow transplant procedure. We have put together a world class team of nurses and support staff. Child life, psychology and social work. We are part of the Florida Hospital for Children and all the support physician services such as ICU, Pulmonology, radiology, surgery etc. are available to us. We have partnered with University of Chicago for nurse training and with Joanne Kurtzberg from Duke University for clinical consultation and patient care. We are off to a superb start and feel truly blessed that Florida Hospital has committed the resources and support to build this unit. It is a very exciting time here at Florida Hospital for Children and I am looking forward to increased patient referrals for consultation. Dr. Paul Gordon is medical director of pediatric bone marrow transplant at Florida Hospital for Children.  Be sure and check out our NEW and IMPROVED website at www.floridamd.com! Powerball & Real Estate Offer Similar Choices! 39 Years or Lump Sums? By Frank Ricci If you won $3.9 million dollars in a lottery, would you take $100,000/year for 39 years or a lump sum payout? The IRS offers you a similar choice when it comes to real estate you own or lease? You see, the IRS allows you an opportunity to front load your depreciation deductions to significantly reduce your taxable income during the first few years of ownership. The IRS provision that allows you to take your money now is based upon the concept called Cost Segregation and it can save you money in 4 ways: 1.Whether buying or building a new facility, a CSS allows you to itemize building components into classes, thereby maximizing your depreciation deductions 2.You can deduct equipment costs, replacements or structural failures 3.You can depreciate leasehold improvements 4.You can deduct as a loss, leasehold improvements upon vacating the premises First, let’s define Cost Segregation (CS)? Real estate, as defined by the IRS, is comprised of four elements: 1.Raw Land (not depreciable) 2.Land Improvements (sidewalks, parking areas, etc. depreciable over 15 years) 3.The Building Structure (roof, walls etc. depreciable over 39 years) 4.Personal Property (cabinetry, special electrical, etc. depreciable over 5 or 7 years) Cost Segregation (CS) is a strategy where a dollar value is assigned to each component of a building by a group of experts so that it can be depreciated correctly. For example, a commercial building has an expected life (for IRS purposes) of 39 years while carpeting has an expected life of 5 years. The IRS allows you to depreciate your carpeting and other personal property over 5 years instead of 39 years, thereby lowering your taxable income and saving you money – oftentimes a significant amount of money. How does CSS minimize my taxes? Let’s assume you are constructing a new $5,000,000 facility with the following costs and assumptions: • $1,100,000 - Land Value (LV) • $3,900,000 - Building Value (BV) • 39 years– Standard Building Depreciation Schedule w/o CSS • 35% - Annual Federal Tax rate Under the most commonly used method, your annual depreciation deduction is determined by dividing the Building Value by the Depreciation Rate to get the annual tax deductible expense. ($3,900,000 BV / 39 years = $100,000 annual tax deduction. Multiply the deduction by your tax rate to show the tax benefit or increase in cash flow. $100,000 deduction x 35% tax rate = $35,000 cash benefit Now, let’s evaluate the same property based upon the results of a Cost Segregation Study. The total land value of $1,100,000 is comprised of the cost of raw land ($725,000) plus the cost of land improvements ($375,000) such as utilities, paving and landscaping. The cost of raw land is NOT depreciable while land improvements are depreciated over 15 years. The total building value of $3,900,000 is comprised of the building structure (walls, roofs and mechanical systems) valued at $2,715,000 depreciated over 39 years plus the value of personal property such as cabinetry, flooring, wall coverings, special plumbing and electrical fixtures valued at $1,185,000 depreciated over 5 or 7 years. Divide each asset cost by their depreciation rate to determine the allowable annual deductions for each. Land Improvements: $375,000 / 15 years = $25,000 Building Value: $2,715,000 / 39 years = $69,615 Personal Property: $1,185,000 / 5 years = $237,000 Total tax deduction after Cost Segregation = $331,615 Multiple by the tax rate to get the annual after tax cash benefit. $331,615 deduction x 35% tax rate = $116,065 cash benefit. By using a CSS in the example above, the property owner is able to increase his cash flow by $81,065 per year for the first five years. Deduct as losses equipment failures or replacements! A tremendous benefit of Cost Segregation relates to equipment failures or component replacements. Suppose you purchased or constructed a building last year and the air conditioner fails and must be replaced at it’s original cost of $39,000. • Without a CSS, you would receive no current benefit as A/C is integral to the building FLORIDA MD - SEPTEMBER 2012 31 • With a CSS, you would calculate your basis in that A/C as total cost ($39,000) minus depreciation taken ($39,000/39 years =$1,000) for a tax basis of $38,000. You would then write off $38,000 on your taxes. Depreciate Leasehold Improvements? Leasehold improvements can also be depreciated through the use of a CSS but there are important considerations. The most important is that you MUST itemize which party - landlord or tenant, paid for which improvements and identify their respective costs. This must be identified in the lease or an addendum and the lease must provide the tenant the right to depreciate these items. An allowance is NOT sufficient. To protect yourself, you should hire an experienced medical facility broker to ensure this issue is properly addressed at the very beginning of lease negotiations. Can my accountant offer this service? The IRS requires very strict guidelines in the performance of these studies. Since CS studies require specific knowledge of design & construction, construction costs, approved estimating procedures & cost databases and the relevant tax code, very few accounting firms have the expertise to offer this service in-house. Frank Ricci is Director of Real Estate at Healthcare Realty & Development Services 300 N. New York Avenue, Winter Park, FL 32790-28022. He has over twenty years of medical real estate and development experience. For more information or questions, please feel free to contact Frank at (407) 947-5074 or HealthCareRealtyServices@Gmail.com.  A rarely used added benefit for Leasehold Improvements At the end of your lease, if you have had a CSS performed and kept careful records, you may write off as a loss, all improvements you paid for which you are leaving at the premises. For example: if you paid $10,000 for a new A/C unit and you have depreciated only $2,000 – you can deduct the remaining $8,000 as a loss on your taxes. How does it work? A firm with a team of experts in tax and building design and construction will review all of the information available for your property and create a report which will detail costs for every component of your building or suite. Based upon the cost of each component, a detailed depreciation schedule will be created with a breakdown of each year’s depreciation. This will be forwarded to your tax accountant for inclusion in current and future tax filings. If your property is several years old, there is a catch up provision in the IRS code allowing you to capture deductions you have missed. The cost and amount of time required to prepare this report depends upon the size and complexity of the project and the documentation that exists. Most reports cost between $5,000 and $12,000 (tax deductible) and take approximately 30 days. The best time to hire a CS team is during the design and construction phase, followed by recently completed projects with budgets and cost data. The most challenging project is an existing building where the entire set of design documents and costs must be reconstructed using cost databases and city code multipliers. 32 FLORIDA MD - SEPTEMBER 2012 nursing excellence Saturday, November 10, 2012 Walt Disney Swan and Dolphin Resort March of Dimes Nurse of the Year will honor the contributions of nurses working in Orange, Seminole and Osceola counties during an evening celebration at the Walt Disney World Sponsorship Opportunties Available For more information call 321-274-8619, email, estuart@marchofdimes.com or visit marchofdimes.com/florida Table: $1,500 | Ticket: $150 Media Sponsors working together for stronger, healthier babies CURRENT TOPICS Florida Hospital and Mimic Technologies Use Simulator to Improve Surgical Training The Device Mimics the da Vinci® Robot and Will Allow More Doctors to Perfect Techniques Before Surgery There is no wireless controller or game console, but surgeons are now able to use video game technology to practice their robotic surgery skills before going into the operating room. At the Florida Hospital Nicholson Center, through a new strategic alliance partnership with Mimic Technologies, robotic surgeons will be perfecting new techniques by doing virtual surgery. Each year, the Nicholson Center provides training for more than 10,000 physicians. Now with the Mimic simulator added to the robotic surgery curriculum, doctors will be able to train in a new simulation center inside the Nicholson Center. Video game and, in the near future, virtual reality simulation training is rapidly being adopted as hospitals seek to minimize the learning curve associated with robotic surgery. Mimic Technologies, the company responsible for da Vinci® robot simulation, has provided the latest simulation technology to Florida Hospital to help meet the demand for better training. Dr. Monica Reed, Florida Hospital Celebration Health administrator and Jeff Berkley, founder and CEO of Mimic Technologies “Robotic surgery offers several benefits to patients. It is minimally invasive so there is less scaring and patients generally experience quicker recovery time,” said Dr. Arnold Advincula, medical director of the benign gynecologic surgery program at Florida Hospital Celebration Health. The more physicians we can train to use this technology appropriately, the more patients will be able to benefit. Incorporating the Mimic simulator into training courses gives the doctor and patient additional confidence when entering the operating room.” Mimic will collaborate with the Nicholson Center to develop simulation-based curricula as part of the strategic alliance partnership. The new jointly developed curricula will accelerate the adoption of the latest robotic technologies and techniques and surgeon skill expertise. Today, there are more than 2,000 da Vinci Systems installed in over 1,500 hospitals worldwide. The da Vinci System has been used in nearly 300,000 surgeries to date. However, there are major challenges to providing adequate training for surgeons new to this complex robotic system. Florida Hospital Nicholson Center has created a facility that will utilize the latest technology in robotic simulation training in an effort to set the standard for academic medical centers and professional organizations. Does your Hospitalist Partner Help Your Practice Grow? “This new partnership focuses on educating surgeons at Florida Hospital and beyond about the importance of effective training, in order to save lives and improve cost and quality,” says Jeff Berkley, founder and CEO of Mimic Technologies. “It is our hope that access to quality simulation training will move surgeons more rapidly up the learning curve.” The new simulator technology will also reduce training time spent on the actual da Vinci device, freeing up the surgical robot for elective patient surgeries. Robotic simulation training also reduces costs, as simulation training does not consume disposable instruments or surgical materials. There is also the potential for improving the efficiency of novice surgeons when performing their first robotic cases. This strategic alliance partnership, created by the Florida Hospital Strategic Venture Group, includes joint research and development of advanced technology for training robotic surgeons and to extend this technology to remote telesurgery operations. Mimic’s simulator is a powerful platform for measuring the changes in the skills of robotic surgeons as they receive different types of training. This opens the door for a wide variety of research experiments that will improve the methods of training and certifying robotic surgeons.  Expedited Care & Rapid Response Time for Improved Patient Outcomes CFIM’s on-site presence at multiple hospitals and skilled nursing facilities allow our 40 physicians and 10 Nurse Practitioners to manage a patient’s care 24 hours a day. Extraordinary Control, Convenience & Communication iTrack each of your patients in the hospital or SNF and view diagnosis, labs, medication lists, diagnostic test results, and discharge summaries in real time iConveniently admit patients through the “Direct Admit” functionality iRequest additional communication and initiate a page to our physicians from the system iRely on CFIM’s dedicated office team of 15 professionals with extended office hours and aroundthe-clock electronic access to serve you and your staff Appreciation of Your Medicare Advantage Challenges CFIM has a dedicated team of Patient Advocates to communicate with your Medicare patients to ensure our entire practice is attuned to patient satisfaction and improving quality measures. To receive more information on CFIM and our Physicians, contact Jim DeFalco @ (407) 647-2346 +%&'"-$0!$'-*.$0.t888$'-*.$0. FLORIDA MD - SEPTEMBER 2012 33 CURRENT TOPICS First Patient in Eastern U.S. Enrolls in Metastatic Melanoma Clinical Trial at Lakeland Regional Cancer Center Lakeland Regional Cancer Center (LRCC) is proud to have been initiated as the only enrolling site in the eastern United States for a metastatic melanoma clinical trial, and one patient, in particular, is filled with hope because this ground-breaking option is offered within driving distance from his home in St. Petersburg. Military Veteran Carl Hall, 79 years, was diagnosed with melanoma six years ago, after inquiring about a shiny mole he discovered on his chest. The cancer was removed in its entirety, along with multiple lymph nodes which all came back clear. Hall was cancer free and bound and determined to enjoy every moment of his life. Three years later, Hall learned the melanoma had returned. He was referred to Lakeland Regional’s Helen Chan, M.D., a boardcertified surgical oncology specialist, who joined him in the fight of his life. “It meant the world to me to have a specialist on my side who wanted what I wanted,” said Hall. “She has a personality that sets you at ease. She listened to what I wanted and presented every option.” In 2012, his list of options grew when he learned about LRCC’s new clinical trial, in which cancerous tumors are treated with a potential breakthrough therapy to include a new medication and a mild electrical current. Hall, who is known for doing his homework and asking for second opinions, liked what he learned about the trial – especially since early data revealed the treatment may help destroy cancer while leaving healthy cells intact. Now just a week into the trial treatment, Hall says he is filled with hope since he has already seen the tumors in his neck shrink in size. “To already see positive reDr. Helen Chan with Carl Hall, the sults without the harsh treatfirst patient to enroll in a potential ments and side effects I’ve exbreakthrough melanoma clinical trial perienced in the past is what at LRCC. means the most to me, said Hall. “I am fighting this cancer, while still living life to the fullest.” Hall says another reason he wanted to take part in the clinical trial is because it had the potential to help many others facing cancer. “Now that I’m in the midst of it, I want others in my situation to know what this treatment has the potential to do for them – to offer a cure, of sorts, not just remission.” To learn more about LRCC and its clinical trials program please call 863-904-1900 or visit www.LRMC.com/cancer-center.  Arnold Palmer Hospital Opens Feeding Difficulties Center Florida’s First Center for Children Unable to Eat by Mouth Arnold Palmer Hospital for Children is opening Florida’s first outpatient intensive feeding center dedicated to treating children with feeding difficulties. The new Feeding Difficulties Center will be located on the seventh floor of the hospital and will work with families to treat young patients with a variety of feeding difficulties due to: • Sensory/aversion disorders • Swallowing disorders • Oral-motor problems • Behavior-related food refusal Children at the Feeding Difficulties Center will be cared for by a multi-disciplinary team of medical professionals, including gastroenterologists, occupational therapists, speech-language pathologists, registered dietitians, clinical social workers, and others. The center will treat children up to age 12. Once referred to the center, patients will be enrolled in a four-week program. Each patient will receive a full day of treatment five days a week. Up to four children can be treated in the center at once. The Feeding Difficulties Center features four patient observation rooms equipped with video recording/monitoring, a private consultation room, an observation room for parents, and a patient gym designated for sensory integration activities. “The Feeding Difficulties Center is fulfilling a real need in Central Florida,” stated Devendra Mehta, M.D., pediatric gastroenterologist at Arnold Palmer Hospital. “We’re seeing many children not physically growing because they are unable to eat. This center is the next step in treating these children and helping them thrive.”  34 FLORIDA MD - SEPTEMBER 2012 CURRENT TOPICS Florida Hospital DeLand Wins the TransLife Award of Excellence: Hospital Reaches a 100 Percent Organ Donation R0ate in 2011 TransLife recently presented Florida Hospital DeLand the TransLife Award of Excellence. TransLife is a federally-designated organ procurement organization for 10 counties in east Central Florida, responsible for the recovery, preservation and distribution of donated organs to critically ill patients. The award is in recognition of exceptional hospital clinical and quality performance practices contributing to high rates of lifesaving organ donations meeting or exceeding national goals. The TransLife Award of Excellence recognizes a 100 percent organ donation rate for Florida Hospital DeLand in 2011. The award is a testament to the quality of the entire clinical team at Florida Hospital DeLand, especially nurses, who are responsible for notifying TransLife of every death and imminent death, should there be potential for donation. Due to the generosity of organ donors and their families, more than three lives were saved through transplantation in 2011.  DR. REUSS WINS 2012 INJURED WORKERS INSPIRATION AWARD Given at the 67th Annual Workers’ Compensation Educational Conference in Orlando Orlando Orthopaedic Center’s Bryan L. Reuss, M.D., was presented with the 2012 Injured Workers Inspiration Award at the 67th Annual Workers’ Compensation Educational Conference for his work with a workers’ compensation patient who sustained an acetabular labral tear (damage to cartilage and tissue in the hip socket) and subsequently required hip arthroscopy surgery. The patient, a stuntman at Disney’s Hollywood Studios theme park in Orlando, Fla., fell off of his motorcycle during a show and slid hundreds of feet on his hip before coming to a stop. After failing to recover from the injury during weeks of extensive conservative therapy, the hip arthroscopy procedure was performed by Dr. Reuss. After 10 weeks of rehabilitation following surgery, the patient is back on his motorcycle, working full duty as one of the main stuntmen in the popular theme park attraction. “I think I speak for the entire Orlando Orthopaedic Center team when I say it’s an honor to help anyone who chose our practice for treatment return to work or get back to their day-to-day activities without pain, as tame or as dangerous as those activities may be,” says Dr. Reuss. “The award is recognition for the effort we put forth every day with every patient in our offices.”  Bryan L. Reuss, M.D. Board Certified in Orthopaedic Surgery, Board Certified in Sports Medicine; Specializing in Sports Medicine, Knee and Shoulder Surgery 89 for only Our full service hotel is located in the heart of Downtown Orlando close to ORMC, MD Anderson, Arnold FLORIDA MD Palmer and Winnie Palmer Hospitals, RATE and Florida Hospital main campus. 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The new cancer of only two locations in Central Florida offering this advanced treatment facility, a 16,500 square foot building located across the street from radiation technology. Health Central, also houses a Varian TrueBeam™ medical linear accelerator machine. This is one of only two locations in Central Florida offering this advanced radiaADVERTISERS INDEX tion technology which treats breast, lung and prostate cancer patients. “We are thrilled to be able to bring cancer services right to west Orange County,” said Greg Ohe, President, Health Central Hospital. “We continue to see the number of men and women diagnosed Center for with cancer climbing and by having these services at Health Central, cancer patients can Specialized Surgery. . . . . . . . . . . 17 now receive the best care available right in their own neighborhoods.” The opening of the cancer facility comes following Orlando Health’s acquisition of Health Central this past April. 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